Provider Demographics
NPI:1578639878
Name:SOUTHERN PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:SOUTHERN PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-414-9161
Mailing Address - Street 1:414 GREENWAY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1426
Mailing Address - Country:US
Mailing Address - Phone:304-414-9161
Mailing Address - Fax:
Practice Address - Street 1:414 GREENWAY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1426
Practice Address - Country:US
Practice Address - Phone:304-414-9161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003269Medicaid
WV3810003269Medicaid