Provider Demographics
NPI:1033981618
Name:SELF LOVE OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:SELF LOVE OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREOGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARCELLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MED, LPC, CAADC
Authorized Official - Phone:631-805-3257
Mailing Address - Street 1:5927 BELSTON CT
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-3214
Mailing Address - Country:US
Mailing Address - Phone:631-805-3257
Mailing Address - Fax:
Practice Address - Street 1:306 TURNER RD STE A-B
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-6432
Practice Address - Country:US
Practice Address - Phone:631-805-3257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health