Independence Child Therapy Services LLC

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

0810004468 Issued in VA

Legal business name

INDEPENDENCE CHILD THERAPY SERVICES LLC

Practice address

4807A Lauderdale Ave
Virginia Beach, VA 23455-1364

Phone

(757) 460-2057

Fax

(757) 963-9020

NPI assigned

Oct 17, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Linda Bourdon, ED.D., LCP

Title

Director

Phone

(757) 460-2057

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1318809600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1318809600000",
    "number": "1417232802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 55145",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234715145",
            "telephone_number": "757-460-2057",
            "fax_number": "757-963-9020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4807A LAUDERDALE AVE",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234551364",
            "telephone_number": "757-460-2057",
            "fax_number": "757-963-9020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDEPENDENCE CHILD THERAPY SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-17",
        "last_updated": "2011-10-17",
        "status": "A",
        "authorized_official_last_name": "BOURDON",
        "authorized_official_first_name": "LINDA",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "757-460-2057",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "ED.D., LCP"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": "VA",
            "license": "0810004468",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Virginia Beach, VA
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.