Healthcare Provider Details

I. General information

NPI: 1669970646
Provider Name (Legal Business Name): DISTRICT 19 COMMUNITY SERVICES BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W BANK ST STE 5
PETERSBURG VA
23803-3279
US

IV. Provider business mailing address

20 W BANK ST STE 7
PETERSBURG VA
23803-3279
US

V. Phone/Fax

Practice location:
  • Phone: 804-862-6082
  • Fax: 804-862-6158
Mailing address:
  • Phone: 804-862-6082
  • Fax: 804-862-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number184
License Number StateVA

VIII. Authorized Official

Name: MRS. LISA A NEWBY
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 804-862-6082