=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790247914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEP UP PEDIATRIC AND ADOLESCENT WELLNESS CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2019
-----------------------------------------------------
Last Update Date | 08/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 ALBEMARLE SQ
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-769-7920
-----------------------------------------------------
Fax | 336-765-8605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 843
-----------------------------------------------------
City | CROZET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22932-0801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-769-7920
-----------------------------------------------------
Fax | 336-765-8605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D.
-----------------------------------------------------
Name | LETICIA HELLEBY-HARDY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 336-769-7920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------