MEDICARE: DOMINION OUTPATIENT 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	101Y00000X	Counselor
2	1041C0700X	Clinical Social Worker	0904005557	VA
3	106H00000X	Marriage & Family Therapist
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1790932911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION OUTPATIENT SERVICES, LLC

Provider Business Mailing Address
First Line	:	8100 THREE CHOPT RD RM 143
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-4833
Country	:	US
Telephone Number	:	804-914-4271
Fax Number	:	804-285-9839

Provider Business Practice Location Address
First Line	:	8100 THREE CHOPT RD RM 101
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-4833
Country	:	US
Telephone Number	:	804-914-4271
Fax Number	:	804-285-9839

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	EBONY COWAN
Credential	:
Telephone Number	:	804-988-7093

Provider Enumeration Date	:	08/19/2008
Last Update Date	:	07/11/2025

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