Healthcare Provider Details

I. General information

NPI: 1649217522
Provider Name (Legal Business Name): DOMINION CHRISTIAN SCHOOL FOR AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6818 W GRACE ST
RICHMOND VA
23226-2831
US

IV. Provider business mailing address

4108 E PARHAM RD
RICHMOND VA
23228-2754
US

V. Phone/Fax

Practice location:
  • Phone: 804-355-0300
  • Fax: 804-355-0932
Mailing address:
  • Phone: 804-355-0300
  • Fax: 804-355-0932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133000086
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0134000035
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133000126
License Number StateVA

VIII. Authorized Official

Name: MS. PAMELA J. WATERMAN
Title or Position: OPERATIONS COORDINATOR
Credential:
Phone: 804-355-0300