=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104380831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRADLESPEED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2019
-----------------------------------------------------
Last Update Date | 04/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2075 HARDING RD
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-9129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-604-7540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2075 HARDING RD
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-9129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-604-7540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/MANAGER
-----------------------------------------------------
Name | MS. TAMARA A. GHOSH
-----------------------------------------------------
Credential | M.S.S.W., L.C.S.W.
-----------------------------------------------------
Telephone | 757-604-7540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------