Provider Demographics
NPI:1457091415
Name:SHADBOLT, ALYSSA FAITH (LCSW)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:FAITH
Last Name:SHADBOLT
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 1:3910 OLD BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5757
Mailing Address - Country:US
Mailing Address - Phone:804-464-8803
Mailing Address - Fax:
Practice Address - Street 1:3910 OLD BUCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-5757
Practice Address - Country:US
Practice Address - Phone:804-464-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040138591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467448571Medicaid