Healthcare Provider Details

I. General information

NPI: 1114784634
Provider Name (Legal Business Name): MAGDALENA GRACE OTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 POCOSHOCK PL STE 102
NORTH CHESTERFIELD VA
23235-6345
US

IV. Provider business mailing address

2500 POCOSHOCK PL STE 102
NORTH CHESTERFIELD VA
23235-6345
US

V. Phone/Fax

Practice location:
  • Phone: 804-562-8705
  • Fax:
Mailing address:
  • Phone: 804-562-8705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0134000634
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: