Provider Demographics
NPI:1033321237
Name:CORNERSTONE SERVICE INTERVENTION SYSTEMS
Entity Type:Organization
Organization Name:CORNERSTONE SERVICE INTERVENTION SYSTEMS
Other - Org Name:CORNERSTONE CHILD AND FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:STONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:757-464-2470
Mailing Address - Street 1:4620 HAYGOOD RD STE 6
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5401
Mailing Address - Country:US
Mailing Address - Phone:757-464-2470
Mailing Address - Fax:
Practice Address - Street 1:4620 HAYGOOD RD STE 6
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5401
Practice Address - Country:US
Practice Address - Phone:757-464-2470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA915 05 001261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADMHMRSASOtherLICENSE # 915 05 001