Provider Demographics
NPI:1528594470
Name:PENINSULA BEHAVIORAL CONSULTING
Entity Type:Organization
Organization Name:PENINSULA BEHAVIORAL CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:757-329-6790
Mailing Address - Street 1:125 SEMPLE FARM RD
Mailing Address - Street 2:APT 103
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1459
Mailing Address - Country:US
Mailing Address - Phone:757-329-6790
Mailing Address - Fax:
Practice Address - Street 1:125 SEMPLE FARM RD
Practice Address - Street 2:APT 103
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1459
Practice Address - Country:US
Practice Address - Phone:757-329-6790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000176251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health