=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760223564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISA N DATCHER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24282 JAMES MONROE HWY
-----------------------------------------------------
City | ALDIE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20105-2732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-615-4177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9721 INKWOOD DR
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22407-9344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-244-3189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------