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General NPI Number Information
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NPI Number | 1033598982
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Entity Type | Organization
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Legal Business Name | ALTITUDE IOP, LLC
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Dates
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Enumeration Date | 05/26/2015
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Last Update Date | 05/26/2015
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Provider Practice Location Address
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Address Line | 708 S MAIN ST
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City | BLACKSBURG
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State | VA
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Zip | 24060-5210
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Country | US
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Telephone | 540-953-5090
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Fax | 540-953-5095
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Provider Business Mailing Address
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Address Line | 708 S MAIN ST
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City | BLACKSBURG
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State | VA
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Zip | 24060-5210
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Country | US
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Telephone | 540-953-5090
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Fax | 540-953-5095
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Authorized Official
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Title or Position | PROGRAM THERAPIST
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Name | KARLA SOUKUP
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Credential | LMFT
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Telephone | 540-953-5090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0717001173
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 953736
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License Number State | VA
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