Healthcare Provider Details

I. General information

NPI: 1790465474
Provider Name (Legal Business Name): UNIQUELY DIFFERENT THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 REBEL RD
CHESAPEAKE VA
23322-3523
US

IV. Provider business mailing address

533 REBEL RD
CHESAPEAKE VA
23322-3523
US

V. Phone/Fax

Practice location:
  • Phone: 757-777-5240
  • Fax:
Mailing address:
  • Phone: 757-777-5240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SABRINA GORDON
Title or Position: OWNER
Credential:
Phone: 757-777-5240