Healthcare Provider Details

I. General information

NPI: 1376919241
Provider Name (Legal Business Name): THE DEVELOPMENTAL ADVANTAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KILLEN HOLLOW DR
CROSS LANES WV
25313-3516
US

IV. Provider business mailing address

PO BOX 7533
CHARLESTON WV
25356-0533
US

V. Phone/Fax

Practice location:
  • Phone: 304-881-2585
  • Fax:
Mailing address:
  • Phone: 304-881-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1125
License Number StateWV

VIII. Authorized Official

Name: CATHY JO HIGGINS
Title or Position: OWNER
Credential:
Phone: 304-881-2585