Provider Demographics
NPI:1760222103
Name:SLADE, SERENITY
Entity type:Individual
Prefix:
First Name:SERENITY
Middle Name:
Last Name:SLADE
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 1:188 ONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-3805
Mailing Address - Country:US
Mailing Address - Phone:540-645-4777
Mailing Address - Fax:
Practice Address - Street 1:188 OVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556
Practice Address - Country:US
Practice Address - Phone:540-645-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-24-349386103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst