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General NPI Number Information
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NPI Number | 1740858836
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Entity Type | Organization
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Legal Business Name | COMMUNITY INTERVENTION GROUP, LLC
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Dates
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Enumeration Date | 06/15/2021
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Last Update Date | 06/15/2021
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Provider Practice Location Address
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Address Line | 205A TEMPLE AVE
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City | COLONIAL HEIGHTS
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State | VA
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Zip | 23834-2827
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Country | US
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Telephone | 804-715-7022
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Fax |
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Provider Business Mailing Address
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Address Line | 5700 FOX HUNT TRL
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City | SOUTH CHESTERFIELD
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State | VA
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Zip | 23803-2284
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Country | US
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Telephone | 804-715-7022
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | LAKEISHA BRANCH
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Credential |
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Telephone | 804-715-7022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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