MEDICARE: COMMUNITY LIVING, INC

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	251C00000X	Developmentally Disabled Services Day Training Agency	823	VA
2	1041C0700X	Clinical Social Worker	0904004677	VA

General Provider Information

NPI Number	:	1912197559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY LIVING, INC

Provider Business Mailing Address
First Line	:	PO BOX 876
Second Line	:
City	:	BRACEY
State	:	VA
Zip	:	23919-0876
Country	:	US
Telephone Number	:	434-447-8381
Fax Number	:	434-447-8381

Provider Business Practice Location Address
First Line	:	314 E ATLANTIC ST
Second Line	:
City	:	SOUTH HILL
State	:	VA
Zip	:	23970-2006
Country	:	US
Telephone Number	:	434-447-8381
Fax Number	:	434-447-8381

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	TERI BISTARKEY
Credential	:	LCSW
Telephone Number	:	434-447-8381

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	07/30/2007

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