MEDICARE: BALM OF GILEAD COUNSELING SERVICES

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	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1770240228	OTHER	VA	CIGNA
2	1770240228	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1548983224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALM OF GILEAD COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	2064 BURSON DR
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23323-5304
Country	:	US
Telephone Number	:	434-632-8041
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 MILL CREEK PKWY
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23323-1098
Country	:	US
Telephone Number	:	434-632-8041
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OLADAYO O OLUWALOLA
Credential	:	LCSW
Telephone Number	:	434-632-8041

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	09/19/2022

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