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General NPI Number Information
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NPI Number | 1619514312
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Entity Type | Organization
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Legal Business Name | GLORY DAYS SUPPORT SERVICE, LLC
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Dates
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Enumeration Date | 12/02/2019
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Last Update Date | 12/02/2019
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Provider Practice Location Address
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Address Line | 625 PINEY FOREST RD, SUITE 302C, SAME
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City | DANVILLE
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State | VA
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Zip | 24540
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Country | US
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Telephone | 434-421-2196
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Fax | 434-688-4713
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Provider Business Mailing Address
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Address Line | 625 PINEY FOREST RD, SUITE 302C, SAME
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City | DANVILLE
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State | VA
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Zip | 24540
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Country | US
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Telephone | 434-421-2196
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Fax | 434-688-4713
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Authorized Official
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Title or Position | CEO/OWNER
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Name | CAMILLA KAYCEO HENRY PETTY
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Credential |
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Telephone | 434-688-4711
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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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