Healthcare Provider Details

I. General information

NPI: 1801485354
Provider Name (Legal Business Name): SUPPORTIVE CARE OF VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 E ELLERSLIE AVE
COLONIAL HEIGHTS VA
23834-1720
US

IV. Provider business mailing address

27 RANDOLPH RD
HOWELL NJ
07731-8611
US

V. Phone/Fax

Practice location:
  • Phone: 718-298-7345
  • Fax:
Mailing address:
  • Phone: 718-298-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: RAPHAEL LICHTSCHEIN
Title or Position: PRESIDENT
Credential:
Phone: 718-298-4375