Healthcare Provider Details

I. General information

NPI: 1720391022
Provider Name (Legal Business Name): DANIELLE JACKSON LIPPOLDT M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 EDWIN DR
VIRGINIA BEACH VA
23462-4522
US

IV. Provider business mailing address

373 EDWIN DR
VIRGINIA BEACH VA
23462-4522
US

V. Phone/Fax

Practice location:
  • Phone: 757-803-5663
  • Fax: 757-938-6944
Mailing address:
  • Phone: 757-301-2411
  • Fax: 888-966-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202005994
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133000608
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: