MEDICARE: MARIEHEAVENLEE BLESSINGS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073332615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIEHEAVENLEE BLESSINGS LLC

Provider Business Mailing Address
First Line	:	3707 PENNYWEIGHT CT
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23237-1977
Country	:	US
Telephone Number	:	804-955-7134
Fax Number	:

Provider Business Practice Location Address
First Line	:	3707 PENNYWEIGHT CT
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23237-1977
Country	:	US
Telephone Number	:	804-955-7134
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. MONIQUE ALTERISS CLARK
Credential	:	BSW, QMHP
Telephone Number	:	804-955-7134

Provider Enumeration Date	:	10/09/2024
Last Update Date	:	10/09/2024

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