Healthcare Provider Details

I. General information

NPI: 1619255601
Provider Name (Legal Business Name): SOUTH CENTRAL COUNSELING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 MAIN STREET
DILLWYN VA
23936
US

IV. Provider business mailing address

977 DEVON SPRING CT
CHARLOTTESVILLE VA
22903-7833
US

V. Phone/Fax

Practice location:
  • Phone: 434-808-0604
  • Fax: 434-808-0716
Mailing address:
  • Phone: 804-683-5306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006760
License Number StateVA

VIII. Authorized Official

Name: STACI L VINSON
Title or Position: DIRECTOR
Credential: LCSW
Phone: 804-683-5306