Healthcare Provider Details

I. General information

NPI: 1306178231
Provider Name (Legal Business Name): CHARLOTTESVILLE LEAGUE OF THERAPISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 MAIN ST SUITE 4
DANVILLE VA
24541-1800
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 Code101Y00000X
TaxonomyCounselor
License Number411-05-001
License Number StateVA

VIII. Authorized Official

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