Provider Demographics
NPI:1679234744
Name:PROSPERITY BEHAVIORAL HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:PROSPERITY BEHAVIORAL HEALTHCARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:323-420-8787
Mailing Address - Street 1:11912 HAYES STATION WAY
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4845
Mailing Address - Country:US
Mailing Address - Phone:323-420-8787
Mailing Address - Fax:443-331-4441
Practice Address - Street 1:11912 HAYES STATION WAY
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4845
Practice Address - Country:US
Practice Address - Phone:323-420-8787
Practice Address - Fax:443-331-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1992015887OtherNPI