=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558053991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACTING FUTURES COMMUNITY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2023
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325-B BROWN ST. SUITE 127
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-924-7471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325-B BROWN ST. SUITE 127
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-924-7471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | ANITRA CARTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-383-4183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------