Provider Demographics
NPI:1417232802
Name:INDEPENDENCE CHILD THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:INDEPENDENCE CHILD THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURDON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LCP
Authorized Official - Phone:757-460-2057
Mailing Address - Street 1:PO BOX 55145
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-5145
Mailing Address - Country:US
Mailing Address - Phone:757-460-2057
Mailing Address - Fax:757-963-9020
Practice Address - Street 1:4807A LAUDERDALE AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-1364
Practice Address - Country:US
Practice Address - Phone:757-460-2057
Practice Address - Fax:757-963-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004468103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty