Provider Demographics
NPI:1487855003
Name:OLD TOWNE COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:OLD TOWNE COUNSELING SERVICES, LLC
Other - Org Name:NA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERI
Authorized Official - Middle Name:DICKINSON
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-398-8401
Mailing Address - Street 1:4197 ROCKHILL RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-6903
Mailing Address - Country:US
Mailing Address - Phone:804-398-8401
Mailing Address - Fax:866-499-8549
Practice Address - Street 1:7293 SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-2129
Practice Address - Country:US
Practice Address - Phone:804-398-8401
Practice Address - Fax:866-499-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty