Provider Demographics
NPI:1639596273
Name:LA MARIPOSA, LLC
Entity type:Organization
Organization Name:LA MARIPOSA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CVO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-403-0429
Mailing Address - Street 1:475 WATER ST
Mailing Address - Street 2:UNIT 604
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3819
Mailing Address - Country:US
Mailing Address - Phone:757-403-0429
Mailing Address - Fax:757-466-9966
Practice Address - Street 1:3568 KARLIN AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3111
Practice Address - Country:US
Practice Address - Phone:757-466-9999
Practice Address - Fax:757-466-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2037320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities