=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942875802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EARLY CHILDHOOD INTERVENTIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2021
-----------------------------------------------------
Last Update Date | 05/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4002 MEADOWS CT
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-8357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-287-0680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4002 MEADOWS CT
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-8357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-287-0680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARIAH ANTIONETTE PETITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-287-0680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------