Basic Information
| Provider Information | |||||||||
| NPI: | 1295743052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGION TEN CSB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 PRESTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229034420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349721800 | ||||||||
| FaxNumber: | 4349702104 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 PRESTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229034420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349721800 | ||||||||
| FaxNumber: | 4349702104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAGLAND | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ACCOUNT TECH | ||||||||
| AuthorizedOfficialTelephone: | 4349721800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | 0904002900 | VA | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 11478114 | 01 | VA | CAQH PROVIDER ID | OTHER |