Healthcare Provider Details

I. General information

NPI: 1376717165
Provider Name (Legal Business Name): CHARLOTTESVILLE LEAGUE OF THERAPISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5355
US

IV. Provider business mailing address

911 E JEFFERSON ST
CHARLOTTESVILLE VA
22902-5355
US

V. Phone/Fax

Practice location:
  • Phone: 434-984-0023
  • Fax: 434-984-4852
Mailing address:
  • Phone: 434-984-0023
  • Fax: 434-984-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number411-05-001
License Number StateVA

VIII. Authorized Official

Name: VICTORIA GIBSON
Title or Position: HR ASSISTANT
Credential:
Phone: 434-984-0023