=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508679887
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS DALE TRAMMELL LMHP-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2025
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 490 PINEY FOREST RD
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-4060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-797-1094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3872 MOUNT TABOR RD
-----------------------------------------------------
City | KEELING
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24566-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-429-1416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0906014931
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------