Basic Information
| Provider Information | |||||||||
| NPI: | 1417247909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELIZABETH A BRILL PHD LCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4127 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240150127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409819394 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Practice Location | |||||||||
| Address1: | 6964 FOREST HILL AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232251606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043865654 | ||||||||
| FaxNumber: | 8043208738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 04/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | BRILL | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 80438656408 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD-LCP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 0810003263 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 1427116946 | 05 | VA | MEDICAID |