Healthcare Provider Details

I. General information

NPI: 1033598982
Provider Name (Legal Business Name): ALTITUDE IOP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 S MAIN ST
BLACKSBURG VA
24060-5210
US

IV. Provider business mailing address

708 S MAIN ST
BLACKSBURG VA
24060-5210
US

V. Phone/Fax

Practice location:
  • Phone: 540-953-5090
  • Fax: 540-953-5095
Mailing address:
  • Phone: 540-953-5090
  • Fax: 540-953-5095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001173
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number953736
License Number StateVA

VIII. Authorized Official

Name: KARLA SOUKUP
Title or Position: PROGRAM THERAPIST
Credential: LMFT
Phone: 540-953-5090