=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043612104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLE INTERVENTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2014
-----------------------------------------------------
Last Update Date | 02/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9850 LORI RD SUITE 101
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23832-6758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-621-4034
-----------------------------------------------------
Fax | 804-621-4091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1330
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23832-9103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-621-4034
-----------------------------------------------------
Fax | 804-200-5413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. BRANDON C HUDSON
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 804-621-4034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2548
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------