Healthcare Provider Details

I. General information

NPI: 1811236227
Provider Name (Legal Business Name): REPLAY COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SOUTHLAKE BLVD
NORTH CHESTERFIELD VA
23236-3060
US

IV. Provider business mailing address

PO BOX 5715
MIDLOTHIAN VA
23112-0030
US

V. Phone/Fax

Practice location:
  • Phone: 804-516-4684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007173
License Number StateVA

VIII. Authorized Official

Name: NIKOLE R JIGGETTS
Title or Position: PRESIDENT/THERAPIST
Credential:
Phone: 804-516-4684