Healthcare Provider Details

I. General information

NPI: 1184863359
Provider Name (Legal Business Name): THERESA ANNE MEDLEY LISW CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 PETER JEFFERSON PKWY STE 250
CHARLOTTESVILLE VA
22911-4655
US

IV. Provider business mailing address

590 PETER JEFFERSON PKWY STE 250
CHARLOTTESVILLE VA
22911-4655
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5000
  • Fax: 804-888-9640
Mailing address:
  • Phone: 804-675-5000
  • Fax: 804-888-9640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8561
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: