Healthcare Provider Details

I. General information

NPI: 1629001896
Provider Name (Legal Business Name): SUPPORTONE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 KENSINGTON AVE STE B
RICHMOND VA
23221-2144
US

IV. Provider business mailing address

2100 W LABUMUM AVE SUITE 104-B
RICHMOND VA
23227
US

V. Phone/Fax

Practice location:
  • Phone: 804-342-7366
  • Fax: 804-342-7368
Mailing address:
  • Phone: 804-340-1845
  • Fax: 804-340-1848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number323
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number323-01-0001
License Number StateVA

VIII. Authorized Official

Name: MRS. CASSANDRA PETTUS SCARBOROUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: CPA
Phone: 804-340-1845