Provider Demographics
NPI:1407589559
Name:AMUNDSEN, ROXANA I (RESIDENT IN COUNSELI)
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:I
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:RESIDENT IN COUNSELI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 THIMBLE SHOALS BLVD
Mailing Address - Street 2:#400
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3562
Mailing Address - Country:US
Mailing Address - Phone:757-838-1960
Mailing Address - Fax:757-838-3280
Practice Address - Street 1:739 THIMBLE SHOALS BLVD
Practice Address - Street 2:#400
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3562
Practice Address - Country:US
Practice Address - Phone:757-838-1960
Practice Address - Fax:757-838-3280
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016728101YP2500X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)