Provider Demographics
NPI:1285331462
Name:MEDICINA MENTIS AD GLORIAM DEI PLLC
Entity type:Organization
Organization Name:MEDICINA MENTIS AD GLORIAM DEI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-490-9500
Mailing Address - Street 1:1083 INDEPENDENCE BLVD STE 187
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5523
Mailing Address - Country:US
Mailing Address - Phone:757-910-2270
Mailing Address - Fax:
Practice Address - Street 1:328 OFFICE SQUARE LN STE 104
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3648
Practice Address - Country:US
Practice Address - Phone:757-490-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty