Provider Demographics
NPI:1194818054
Name:CLINICAL PSYCHOLOGY SERVICES PC
Entity Type:Organization
Organization Name:CLINICAL PSYCHOLOGY SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUXER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-691-1326
Mailing Address - Street 1:11130 FAIRFAX BLVD
Mailing Address - Street 2:STE 305
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5035
Mailing Address - Country:US
Mailing Address - Phone:703-691-1326
Mailing Address - Fax:703-691-3553
Practice Address - Street 1:11130 FAIRFAX BLVD
Practice Address - Street 2:STE 305
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5035
Practice Address - Country:US
Practice Address - Phone:703-691-1326
Practice Address - Fax:703-691-3553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007799195Medicaid
VA647334Medicare PIN