MEDICARE: PSYCHOLOGICAL ASSESSMENT AND INTERVENTION SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	566	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70365	OTHER	WV	UMWA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	001710371	OTHER	WV	MT STATE BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	490712	OTHER	WV	AETNA VALUE OPTIONS

General Provider Information

NPI Number	:	1356475412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL ASSESSMENT AND INTERVENTION SERVICES, LLC

Provider Business Mailing Address
First Line	:	10304 SPOTSYLVANIA AVE STE 300
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22408-8605
Country	:	US
Telephone Number	:	304-346-9586
Fax Number	:	304-344-2169

Provider Business Practice Location Address
First Line	:	1 DUNBAR PLZ STE 100A
Second Line	:
City	:	DUNBAR
State	:	WV
Zip	:	25064-3038
Country	:	US
Telephone Number	:	304-346-9586
Fax Number	:	304-344-2169

Authorized Official
Title or Position	:	WV DIRECTOR OF OPERATIONS
Name	:	LAURA MARIE WHITE
Credential	:
Telephone Number	:	304-992-6153

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/10/2024

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Directions to “PSYCHOLOGICAL ASSESSMENT AND INTERVENTION SERVICES, LLC ” Practice Location

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