Provider Demographics
NPI:1730824996
Name:FOXWORTH, VIRGINIA WALL (LMHC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:WALL
Last Name:FOXWORTH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3916
Mailing Address - Country:US
Mailing Address - Phone:904-556-1642
Mailing Address - Fax:
Practice Address - Street 1:717 S 8TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3702
Practice Address - Country:US
Practice Address - Phone:904-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health