MEDICARE: INDEPENDENCE CHILD THERAPY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	0810004468	VA

General Provider Information

NPI Number	:	1417232802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE CHILD THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 55145
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23471-5145
Country	:	US
Telephone Number	:	757-460-2057
Fax Number	:	757-963-9020

Provider Business Practice Location Address
First Line	:	4807A LAUDERDALE AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-1364
Country	:	US
Telephone Number	:	757-460-2057
Fax Number	:	757-963-9020

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. LINDA BOURDON
Credential	:	ED.D., LCP
Telephone Number	:	757-460-2057

Provider Enumeration Date	:	10/17/2011
Last Update Date	:	10/17/2011

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