Healthcare Provider Details

I. General information

NPI: 1487054342
Provider Name (Legal Business Name): IMPACT LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 BROOK PARK PL STE A1
FOREST VA
24551-2766
US

IV. Provider business mailing address

316 BROOK PARK PL STE A1
FOREST VA
24551-2766
US

V. Phone/Fax

Practice location:
  • Phone: 434-533-1088
  • Fax: 434-664-1177
Mailing address:
  • Phone: 434-533-1088
  • Fax: 434-664-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JANIE DUNCAN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 434-533-1088