Healthcare Provider Details

I. General information

NPI: 1912197559
Provider Name (Legal Business Name): COMMUNITY LIVING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E ATLANTIC ST
SOUTH HILL VA
23970-2006
US

IV. Provider business mailing address

PO BOX 876
BRACEY VA
23919-0876
US

V. Phone/Fax

Practice location:
  • Phone: 434-447-8381
  • Fax: 434-447-8381
Mailing address:
  • Phone: 434-447-8381
  • Fax: 434-447-8381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004677
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number823
License Number StateVA

VIII. Authorized Official

Name: TERI BISTARKEY
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 434-447-8381