Healthcare Provider Details

I. General information

NPI: 1205454972
Provider Name (Legal Business Name): JOSEPHINE EMMA IWATSUBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 COMMONWEALTH DR STE 200
CHARLOTTESVILLE VA
22901-1894
US

IV. Provider business mailing address

1131 SUNSET AVENUE EXT
CHARLOTTESVILLE VA
22903-7861
US

V. Phone/Fax

Practice location:
  • Phone: 804-928-1024
  • Fax:
Mailing address:
  • Phone: 804-928-1024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: