Basic Information
| Provider Information | |||||||||
| NPI: | 1285012591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLE PENINSULA NORTHERN NECK COMMUNITY SERVICES BOARD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5372B OLD VIRGINIA STREET | ||||||||
| Address2: | |||||||||
| City: | URBANNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047585250 | ||||||||
| FaxNumber: | 8047585183 | ||||||||
| Practice Location | |||||||||
| Address1: | 9228 GEORGE WASHINGTON MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | GLOUCESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230614162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046950326 | ||||||||
| FaxNumber: | 8046934822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2015 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EARLY INTERVENTION DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8047585250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.ED. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | Y | Agencies | Early Intervention Provider Agency |
No ID Information.