=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225094451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISTRICT 19 COMMUNITY SERVICES BOARD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2006
-----------------------------------------------------
Last Update Date | 07/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 W BANK ST SUITE 2
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-3279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-862-8054
-----------------------------------------------------
Fax | 804-863-1665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 W BANK ST SUITE 2
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-3279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-862-8054
-----------------------------------------------------
Fax | 804-863-1665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOSEPH E. HUBBARD
-----------------------------------------------------
Credential | C.P.A.
-----------------------------------------------------
Telephone | 804-862-8054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------