Healthcare Provider Details

I. General information

NPI: 1134477060
Provider Name (Legal Business Name): SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 W JACKSON ST SUITE 101
GATE CITY VA
24251-2929
US

IV. Provider business mailing address

142 W JACKSON ST SUITE 101
GATE CITY VA
24251-2929
US

V. Phone/Fax

Practice location:
  • Phone: 276-386-2535
  • Fax:
Mailing address:
  • Phone: 276-386-2535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2451
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004740
License Number StateVA

VIII. Authorized Official

Name: DR. MICHAEL C MCDONOUGH
Title or Position: LICENSED CLINICAL PSYCHOLOGIST/PART
Credential: LCP
Phone: 276-386-2534