Provider Demographics
NPI:1306235783
Name:INDEPENDENCE PSYCHOTHERAPY SERVICES LLC
Entity type:Organization
Organization Name:INDEPENDENCE PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:BOURDON
Authorized Official - Last Name:REIN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LCP
Authorized Official - Phone:757-345-6428
Mailing Address - Street 1:215 MCLAWS CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5799
Mailing Address - Country:US
Mailing Address - Phone:757-345-6428
Mailing Address - Fax:757-345-6808
Practice Address - Street 1:215 MCLAWS CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5799
Practice Address - Country:US
Practice Address - Phone:757-345-6428
Practice Address - Fax:757-345-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07010005880101Y00000X
VA08701003392101Y00000X
VA0810004468103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417232802OtherINDEPENDENCE CHILD THERAPY SERVICES LLC