Provider Demographics
NPI:1033138227
Name:THIMBLE SHOALS COUNSELING & THERAPY CENTER PC
Entity Type:Organization
Organization Name:THIMBLE SHOALS COUNSELING & THERAPY CENTER PC
Other - Org Name:SUSAN C NICHOLSON PHD, LCSW DBA THIMBLE SHOALS COUNSELING & THERAPY CE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:757-869-2361
Mailing Address - Street 1:203 WOODBURNE LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-8363
Mailing Address - Country:US
Mailing Address - Phone:757-869-2361
Mailing Address - Fax:757-223-1165
Practice Address - Street 1:703 THIMBLE SHOALS BLVD
Practice Address - Street 2:A3
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2576
Practice Address - Country:US
Practice Address - Phone:757-873-3401
Practice Address - Fax:757-223-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040030481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA228979000OtherMAGELLAN
VA567827OtherMAMSI
VA5774587OtherAETNA
VA1033138227Medicaid
VA034810OtherVALUE OPTIONS
VA118556OtherANTHEM
VA118556OtherHEALTHKEEPERS
VA081419OtherSENTARA
2130368OtherCIGNA
VA413584OtherMHN
VA081419OtherSENTARA