Provider Demographics
NPI:1710549548
Name:FENTRESS, TOSHIBA ANTONIA
Entity type:Individual
Prefix:
First Name:TOSHIBA
Middle Name:ANTONIA
Last Name:FENTRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 BALLENTINE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509-2304
Mailing Address - Country:US
Mailing Address - Phone:757-831-2741
Mailing Address - Fax:
Practice Address - Street 1:3755 E VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3238
Practice Address - Country:US
Practice Address - Phone:757-823-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008414101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health