Healthcare Provider Details

I. General information

NPI: 1609256478
Provider Name (Legal Business Name): MEDOPTIONS OF VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RESEARCH PKWY
OLD SAYBROOK CT
06475-4214
US

IV. Provider business mailing address

20 RESEARCH PKWY
OLD SAYBROOK CT
06475-4214
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax: 877-515-7147
Mailing address:
  • Phone: 800-370-3651
  • Fax: 877-515-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: DONNA J DOOLEY
Title or Position: CFO
Credential:
Phone: 800-370-3651