Healthcare Provider Details

I. General information

NPI: 1063889327
Provider Name (Legal Business Name): PINWHEEL AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 MEDITERRANEAN AVE
VIRGINIA BEACH VA
23451-4032
US

IV. Provider business mailing address

2508 MEDITERRANEAN AVE
VIRGINIA BEACH VA
23451-4032
US

V. Phone/Fax

Practice location:
  • Phone: 757-803-5663
  • Fax: 757-938-6944
Mailing address:
  • Phone: 757-803-5663
  • Fax: 757-938-6944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133000608
License Number StateVA

VIII. Authorized Official

Name: MRS. DANIELLE JACKSON LIPPOLDT
Title or Position: BEHAVIOR ANALYST
Credential: MA CCC-SLP BCBA LBA
Phone: 757-803-5663