Organization
LA MARIPOSA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. GWENDOLYN LEE CARLISLE (OWNER/CEO)
(757) 403-0429
Entity
Organization
Contact information
Practice address
475 WATER ST APT 604, PORTSMOUTH, VA 23704-3899
(757) 403-0429
Mailing address
475 WATER ST APT 604, PORTSMOUTH, VA 23704-3899
(757) 403-0429
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
2037
VA
Other
Enumeration date
02/07/2013
Last updated
02/07/2013
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