=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124646278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINICHIELLO THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2020
-----------------------------------------------------
Last Update Date | 10/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4169 VIRGINIA BEACH BLVD BLDG SUITE400
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23452-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-346-5007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4169 VIRGINIA BEACH BLVD STE 400
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23452-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RACHEL MINICHIELLO
-----------------------------------------------------
Credential | M.S. ED., CCC-SLP
-----------------------------------------------------
Telephone | 757-346-5007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------