Provider Demographics
NPI:1629063292
Name:MAULL, CHARLOTTE MOORE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MOORE
Last Name:MAULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 LYNNHAVEN PKWY
Mailing Address - Street 2:STE 201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:757-306-4232
Mailing Address - Fax:757-306-4235
Practice Address - Street 1:1215 VOLVO PKWY
Practice Address - Street 2:STE 202
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-312-8550
Practice Address - Fax:757-312-8553
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001746101YM0800X
VA0812000813101YM0800X
VA0717000828106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5410738Medicaid
VA265827OtherBCBS