Basic Information
| Provider Information | |||||||||
| NPI: | 1942226139 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENE COUNTY PUBLIC SCHOOLS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GREENE CNTY PUBLIC SCHOOLS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 225 LAMBS LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229018951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349759400 | ||||||||
| FaxNumber: | 4349759401 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 CELT ROAD | ||||||||
| Address2: | |||||||||
| City: | STANARDSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349855254 | ||||||||
| FaxNumber: | 4349855254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCMANUS | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4349759400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 4980689 | 05 | VA | MEDICAID | 004980689 | 05 | VA | MEDICAID |