Provider Demographics
NPI:1720558075
Name:FLY, DAVID RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:FLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:732 THIMBLE SHOALS BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4262
Mailing Address - Country:US
Mailing Address - Phone:757-873-8566
Mailing Address - Fax:757-595-1885
Practice Address - Street 1:502 STERNBERG AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1527
Practice Address - Country:US
Practice Address - Phone:757-314-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006099103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist