1699705459 NPI number — TREE OF LIFE CHRISTIAN COUNSELING AGENCY, LLC

Table of content: (NPI 1699705459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699705459 NPI number — TREE OF LIFE CHRISTIAN COUNSELING AGENCY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREE OF LIFE CHRISTIAN COUNSELING AGENCY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHILICIA JEFFERSON WILSON
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699705459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 42111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22404-2111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-710-0520
Provider Business Mailing Address Fax Number:
703-490-3544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4936 SOUTHPOINT PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22407-2659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-710-0520
Provider Business Practice Location Address Fax Number:
703-490-3544
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JEFFERSON
Authorized Official First Name:
PHILICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
540-710-0520

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  831 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 258225000 . This is a "MENTAL HEALTH OUTPATIENT" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 441462 . This is a "OUT-PATIENT MENTAL HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010200113 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010276128 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005411041 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com