Provider Demographics
NPI:1134477060
Name:SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES
Entity Type:Organization
Organization Name:SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST/PART
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LCP
Authorized Official - Phone:276-386-2534
Mailing Address - Street 1:142 W JACKSON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-2929
Mailing Address - Country:US
Mailing Address - Phone:276-386-2535
Mailing Address - Fax:
Practice Address - Street 1:142 W JACKSON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-2929
Practice Address - Country:US
Practice Address - Phone:276-386-2535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2451103TC0700X
VA09040047401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1469OtherBUSINESS LICENSE NUMBER