Basic Information
| Provider Information | |||||||||
| NPI: | 1295261444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLE PENINSULA NORTHERN NECK CSB | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5372B OLD VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | URBANNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047585250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5372 OLD VIRGINIA ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | URBANNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231752179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047585250 | ||||||||
| FaxNumber: | 8047585183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8047585250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RURAL INFANT SERVICE PROGRAM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MAED | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | PROV0641855 | VA | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 4978137 | 05 | VA | MEDICAID |