Provider Demographics
NPI:1457848335
Name:PENINSULA CHILD & FAMILY SERVICES LLC
Entity Type:Organization
Organization Name:PENINSULA CHILD & FAMILY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-478-6120
Mailing Address - Street 1:4410 CLAIBORNE SQ E STE 334
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2074
Mailing Address - Country:US
Mailing Address - Phone:757-977-0889
Mailing Address - Fax:757-977-0895
Practice Address - Street 1:4410 CLAIBORNE SQ E STE 334
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2074
Practice Address - Country:US
Practice Address - Phone:757-977-0889
Practice Address - Fax:757-977-0895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040096841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1649717158OtherSOLE PROPRIETOR NUMBER