Healthcare Provider Details

I. General information

NPI: 1063894962
Provider Name (Legal Business Name): HALLIE LIFSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 CLOVELLY RD
RICHMOND VA
23221-3701
US

IV. Provider business mailing address

1610 FOREST AVE
RICHMOND VA
23229-5009
US

V. Phone/Fax

Practice location:
  • Phone: 804-513-6797
  • Fax:
Mailing address:
  • Phone: 804-282-4596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119005726
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: