Provider Demographics
NPI:1215110648
Name:KIRTLAND, DONALD R (MA, PHD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:KIRTLAND
Suffix:
Gender:M
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 KINGS GRANT RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7036
Mailing Address - Country:US
Mailing Address - Phone:714-309-3033
Mailing Address - Fax:
Practice Address - Street 1:648 KINGS GRANT RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7036
Practice Address - Country:US
Practice Address - Phone:714-309-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC47902106H00000X
CALPC220101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional