Provider Demographics
NPI:1790045334
Name:DOMINION ABA
Entity Type:Organization
Organization Name:DOMINION ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:804-285-9838
Mailing Address - Street 1:5408 CHAMBERLAYNE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-2407
Mailing Address - Country:US
Mailing Address - Phone:804-285-9838
Mailing Address - Fax:804-285-9839
Practice Address - Street 1:5408 CHAMBERLAYNE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-2407
Practice Address - Country:US
Practice Address - Phone:804-285-9838
Practice Address - Fax:804-285-9839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOMINION YOUTH SERVICES RESIDENTIAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1654-07-004251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1654-07-004Medicaid