1033138227 NPI number — THIMBLE SHOALS COUNSELING & THERAPY CENTER PC

Table of content: (NPI 1033138227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033138227 NPI number — THIMBLE SHOALS COUNSELING & THERAPY CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THIMBLE SHOALS COUNSELING & THERAPY CENTER PC
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:
Provider Other Organization Name Type Code:
6
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:
1033138227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 WOODBURNE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23602-8363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-869-2361
Provider Business Mailing Address Fax Number:
757-223-1165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 THIMBLE SHOALS BLVD
Provider Second Line Business Practice Location Address:
A3
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23606-2576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-873-3401
Provider Business Practice Location Address Fax Number:
757-223-1165
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLSON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
757-869-2361

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904003048 , 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: 228979000 . This is a "MAGELLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 567827 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5774587 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1033138227 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 034810 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 118556 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 118556 . This is a "HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 081419 . This is a "SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2130368 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 413584 . This is a "MHN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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