Healthcare Provider Details

I. General information

NPI: 1740245117
Provider Name (Legal Business Name): JEFFERSON TRAIL TREATMENT CENTER FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ARLINGTON BLVD
CHARLOTTESVILLE VA
22903-1521
US

IV. Provider business mailing address

2101 ARLINGTON BLVD
CHARLOTTESVILLE VA
22903-1521
US

V. Phone/Fax

Practice location:
  • Phone: 800-777-8855
  • Fax: 703-777-7147
Mailing address:
  • Phone: 800-777-8855
  • Fax: 703-777-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number63014001
License Number StateVA

VIII. Authorized Official

Name: SARA CROWLEY
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 800-777-8855