Provider Demographics
NPI:1619255601
Name:SOUTH CENTRAL COUNSELING GROUP
Entity Type:Organization
Organization Name:SOUTH CENTRAL COUNSELING GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:L
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-683-5306
Mailing Address - Street 1:977 DEVON SPRING CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-7833
Mailing Address - Country:US
Mailing Address - Phone:804-683-5306
Mailing Address - Fax:
Practice Address - Street 1:1046 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DILLWYN
Practice Address - State:VA
Practice Address - Zip Code:23936
Practice Address - Country:US
Practice Address - Phone:434-808-0604
Practice Address - Fax:434-808-0716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040067601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1093004871Medicaid