=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417740598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRYSALIS DISABILITY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2025
-----------------------------------------------------
Last Update Date | 05/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7533 WILLIAMSON RD
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24019-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-632-0849
-----------------------------------------------------
Fax | 540-566-4472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7533 WILLIAMSON RD
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24019-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-632-0849
-----------------------------------------------------
Fax | 540-566-4472
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD CHAIR
-----------------------------------------------------
Name | SICLINDA CANTY-ELLIOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-819-1412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------