Basic Information
| Provider Information | |||||||||
| NPI: | 1629158159 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILD & FAMILY SERVICES OF EASTERN VIRGINIA, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE UP CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 222 W 19TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235172218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576227017 | ||||||||
| FaxNumber: | 7576408402 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 W 19TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235172218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576227017 | ||||||||
| FaxNumber: | 7576408402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 01/19/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | LUVERNE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7576227017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1538364179 | 01 | VA | MARY A BRANTLEY - PROVIDER | OTHER | 1295888501 | 01 | VA | KRISTIN HARDEE-POULIN - PROVIDER | OTHER | 1689689234 | 01 | VA | FREDRICK D WESTON - PROVIDER | OTHER | 1285737205 | 01 | VA | GLORIA M SAUNDERS - PROVIDER | OTHER | 1417028291 | 01 | VA | CONSTANTINA KOUZI | OTHER | 1215917315 | 01 | VA | JAMES ZELL - PROVIDER | OTHER | 1033273560 | 01 | VA | J. KELLIE EVANS - PROVIDER | OTHER | 1194891598 | 01 | VA | ANDREA LONG - PROVIDER | OTHER | 1487764825 | 01 | VA | DEBORAH LEECY - PROVIDER | OTHER | 1487840641 | 01 | VA | SHAWN WARE-AVANT - PROVIDER | OTHER |