Provider Demographics
NPI:1295261444
Name:MIDDLE PENINSULA NORTHERN NECK CSB
Entity type:Organization
Organization Name:MIDDLE PENINSULA NORTHERN NECK CSB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MAED
Authorized Official - Phone:804-758-5250
Mailing Address - Street 1:5372B OLD VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:URBANNA
Mailing Address - State:VA
Mailing Address - Zip Code:23175
Mailing Address - Country:US
Mailing Address - Phone:804-758-5250
Mailing Address - Fax:
Practice Address - Street 1:5372 OLD VIRGINIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175-2179
Practice Address - Country:US
Practice Address - Phone:804-758-5250
Practice Address - Fax:804-758-5183
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RURAL INFANT SERVICE PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPROV0641855252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4978137Medicaid
VA4978137Medicaid