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General NPI Number Information
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NPI Number | 1891145876
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Entity Type | Organization
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Legal Business Name | TAYLOR ENHANCED LIVING
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Dates
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Enumeration Date | 06/21/2016
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Last Update Date | 06/21/2016
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Provider Practice Location Address
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Address Line | 105 HOLLY HILL DIVE SUITE A
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City | PETERSBURG
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State | VA
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Zip | 23805
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Country | US
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Telephone | 804-733-8847
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Fax | 804-732-4963
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Provider Business Mailing Address
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Address Line | 105 HOLLY HILL DIVE SUITE A
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City | PETERSBURG
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State | VA
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Zip | 23805
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Country | US
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Telephone | 804-733-8847
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Fax | 804-732-4963
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. CHARITA LAVONNE THREATT
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Credential | LPC
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Telephone | 804-733-8847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701006556
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License Number State | VA
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