Healthcare Provider Details

I. General information

NPI: 1609103936
Provider Name (Legal Business Name): CENTER FOR DEVELOPMENTAL DIFFERENCES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 VIRGINIA BEACH BLVD SUITE 136
VIRGINIA BEACH VA
23452-1743
US

IV. Provider business mailing address

4000 VIRGINIA BEACH BLVD SUITE 136
VIRGINIA BEACH VA
23452-1743
US

V. Phone/Fax

Practice location:
  • Phone: 757-486-0585
  • Fax:
Mailing address:
  • Phone: 757-486-0585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. JUDIT ROTH
Title or Position: OWNER
Credential: MA
Phone: 757-352-0585