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General NPI Number Information
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NPI Number | 1013206200
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Entity Type | Organization
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Legal Business Name | LEESBURG COMMUNITY CHURCH
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Dates
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Enumeration Date | 03/29/2011
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Last Update Date | 03/29/2011
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Provider Practice Location Address
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Address Line | 815 LEE AVE SW STE B
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City | LEESBURG
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State | VA
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Zip | 20175-3416
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Country | US
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Telephone | 703-777-2209
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Fax |
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Provider Business Mailing Address
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Address Line | 835 LEE AVE SW
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City | LEESBURG
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State | VA
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Zip | 20175-3416
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Country | US
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Telephone | 703-777-2209
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Fax | 703-779-2018
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. TIMOTHY J TEAGUE
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Credential | PH.D.
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Telephone | 703-777-2209
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701001459
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License Number State | VA
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