=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043051642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VA SMILE FOUNDATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 MUSKET LN
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-5345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-927-7477
-----------------------------------------------------
Fax | 757-654-3194
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 COLISEUM XING STE 5142
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-5971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-927-7477
-----------------------------------------------------
Fax | 757-654-3194
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. KENYUATIA LYNN GASH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 757-927-7477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------