Provider Demographics
NPI:1023313590
Name:CVSS MENTAL HEALTH SUPPORT
Entity type:Organization
Organization Name:CVSS MENTAL HEALTH SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DERWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-328-1979
Mailing Address - Street 1:5812 NORTHFORD PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-7590
Mailing Address - Country:US
Mailing Address - Phone:804-328-1790
Mailing Address - Fax:804-328-1793
Practice Address - Street 1:4220 OAKLEYS CT
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5970
Practice Address - Country:US
Practice Address - Phone:804-328-1790
Practice Address - Fax:804-328-1793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA792-03-011251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health