Healthcare Provider Details

I. General information

NPI: 1396193157
Provider Name (Legal Business Name): PROSPERITY EATING DISORDER AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 W MAIN ST
CHARLOTTESVILLE VA
22903-4570
US

IV. Provider business mailing address

1031 STERLING RD STE 203
HERNDON VA
20170-3873
US

V. Phone/Fax

Practice location:
  • Phone: 434-326-4577
  • Fax:
Mailing address:
  • Phone: 703-446-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HEATHER BAKER
Title or Position: DIRECTOR
Credential: LCSW
Phone: 434-326-4577