Provider Demographics
NPI:1508143132
Name:HYPPOLITE, MARIE IMMACULA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:IMMACULA
Last Name:HYPPOLITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 FAYE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-6202
Mailing Address - Country:US
Mailing Address - Phone:434-634-3217
Mailing Address - Fax:434-348-3471
Practice Address - Street 1:546 WALNUT GROVE DR
Practice Address - Street 2:
Practice Address - City:JARRATT
Practice Address - State:VA
Practice Address - Zip Code:23867-8611
Practice Address - Country:US
Practice Address - Phone:434-634-3217
Practice Address - Fax:434-348-3471
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040077671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904007767Medicaid