1992164834 NPI number — PSYCHOLOGICAL AND LIFE SKILLS ASSOCIATION

Table of content: (NPI 1992164834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992164834 NPI number — PSYCHOLOGICAL AND LIFE SKILLS ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGICAL AND LIFE SKILLS ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992164834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 JEFFERSON DAVIS HWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22401-4564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-490-0336
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 JEFFERSON DAVIS HWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22401-4564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-490-0336
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TAFT
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
YARBOROUGH
Authorized Official Title or Position:
CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
571-285-1403

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904009260 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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