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General NPI Number Information
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NPI Number | 1437674900
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Entity Type | Organization
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Legal Business Name | JUNIPER TREE LLC
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Dates
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Enumeration Date | 08/07/2017
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Last Update Date | 05/23/2023
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Provider Practice Location Address
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Address Line | 348 BROAD ST
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City | PORTSMOUTH
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State | VA
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Zip | 23707
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Country | US
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Telephone | 757-619-0658
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Fax |
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Provider Business Mailing Address
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Address Line | 1119 LAKEVIEW DR
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City | PORTSMOUTH
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State | VA
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Zip | 23701-3610
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Country | US
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Telephone | 757-619-0658
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. ANDRE LAMONT POWELL SR.
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Credential |
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Telephone | 757-619-0658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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