Healthcare Provider Details

I. General information

NPI: 1285538314
Provider Name (Legal Business Name): ABUNDANT LIFE SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 VIRGINIA BEACH BLVD STE 218
VIRGINIA BEACH VA
23452-3412
US

IV. Provider business mailing address

3707 VIRGINIA BEACH BLVD STE 218
VIRGINIA BEACH VA
23452-3412
US

V. Phone/Fax

Practice location:
  • Phone: 948-220-6449
  • Fax:
Mailing address:
  • Phone: 948-220-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: TARNISHA DENISE WADDLER
Title or Position: CEO
Credential: QMHP A&C
Phone: 948-220-6449