Provider Demographics
NPI:1396078069
Name:PROVIDENCE CONSULTING AND CLINICAL SERVICES
Entity type:Organization
Organization Name:PROVIDENCE CONSULTING AND CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:YARHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:757-348-8680
Mailing Address - Street 1:1989 BLUE KNOB RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7435
Mailing Address - Country:US
Mailing Address - Phone:757-348-8680
Mailing Address - Fax:
Practice Address - Street 1:1000 REGENT UNIVERSITY DR
Practice Address - Street 2:CRB 161
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5037
Practice Address - Country:US
Practice Address - Phone:757-348-8680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000366103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty