Healthcare Provider Details

I. General information

NPI: 1851210561
Provider Name (Legal Business Name): TAMI JO PEBSWORTH CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

6334 PETERS CREEK RD
HOLLINS VA
24019-4024
US

IV. Provider business mailing address

82 DOWNING ST
ROANOKE VA
24019-8279
US

V. Phone/Fax

Practice location:
  • Phone: 540-503-3779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103395
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: