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General NPI Number Information
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NPI Number | 1225705510
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Entity Type | Organization
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Legal Business Name | SEA GLASS LLC
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Dates
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Enumeration Date | 08/25/2021
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Last Update Date | 08/25/2021
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Provider Practice Location Address
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Address Line | 5318 PATTERSON AVE STE C
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City | RICHMOND
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State | VA
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Zip | 23226-2044
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Country | US
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Telephone | 804-217-2202
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Fax | 833-699-4700
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Provider Business Mailing Address
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Address Line | 5318 PATTERSON AVE STE C
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City | RICHMOND
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State | VA
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Zip | 23226-2044
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Country | US
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Telephone | 804-217-2202
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Fax | 833-699-4700
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER JENKINS-BOITNOTT
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Credential |
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Telephone | 804-217-2202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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