Healthcare Provider Details

I. General information

NPI: 1609031632
Provider Name (Legal Business Name): PROVIDENCE HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 VARNUM ST NE STE 100
WASHINGTON DC
20017
US

IV. Provider business mailing address

1150 VARNUM ST NE ST CATHERINES HALL 102
WASHINGTON DC
20017-2180
US

V. Phone/Fax

Practice location:
  • Phone: 202-854-7623
  • Fax: 202-854-7616
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-269-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberHFD01-0212
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberHFD01-0212
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberHFD01-0212
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberHFD01-0212
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberHFD01-0212
License Number StateDC
# 6
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

Name: MITCHELL LOMAX
Title or Position: VICE PRESIDENT/CFO
Credential:
Phone: 667-234-2926