Healthcare Provider Details

I. General information

NPI: 1639566789
Provider Name (Legal Business Name): INTERCEDING CONSULTANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 05/26/2021
Certification Date: 05/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 GLENSIDE DR STE F
RICHMOND VA
23228-3995
US

IV. Provider business mailing address

1140 WILKINSON RD
RICHMOND VA
23227-1623
US

V. Phone/Fax

Practice location:
  • Phone: 804-997-7962
  • Fax: 877-333-0229
Mailing address:
  • Phone: 804-997-7962
  • Fax: 877-333-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EDWARD TILLMAN
Title or Position: CEO
Credential:
Phone: 804-301-6410