Healthcare Provider Details

I. General information

NPI: 1710468665
Provider Name (Legal Business Name): JUN-LIZZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 MYLAN RD
RICHMOND VA
23223-2273
US

IV. Provider business mailing address

4325 MYLAN RD
RICHMOND VA
23223-2273
US

V. Phone/Fax

Practice location:
  • Phone: 804-767-9723
  • Fax:
Mailing address:
  • Phone: 804-767-9723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0732000133
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0711000285
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0732000133
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0732000133
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0735000015
License Number StateVA
# 6
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number0732000133
License Number StateVA

VIII. Authorized Official

Name: CRYSTAL LESTER-LEWIS
Title or Position: OWNER
Credential: BS QMHP RPRS CSAC-A
Phone: 804-767-9723