Provider Demographics
NPI:1447404082
Name:PROVIDENCE SERVICE CORPORATION
Entity Type:Organization
Organization Name:PROVIDENCE SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:512-343-8606
Mailing Address - Street 1:2211 E MISSOURI AVE
Mailing Address - Street 2:E243
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-3807
Mailing Address - Country:US
Mailing Address - Phone:915-545-8137
Mailing Address - Fax:915-838-1772
Practice Address - Street 1:2211 E MISSOURI AVE
Practice Address - Street 2:E243
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3807
Practice Address - Country:US
Practice Address - Phone:915-545-8137
Practice Address - Fax:915-838-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization