=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770711905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPEUTIC IMPRESSIONS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2009
-----------------------------------------------------
Last Update Date | 06/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 PINEY FOREST RD
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-414-1460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 FARNINGHAM LN
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-6890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | TAKISHA CRAWFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-414-1460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------