Healthcare Provider Details

I. General information

NPI: 1982333167
Provider Name (Legal Business Name): SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 276-386-2534
  • Fax: 276-386-2535
Mailing address:
  • Phone: 276-386-2534
  • Fax: 276-386-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICAHEL C MCDONOUGH
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: ED.D
Phone: 276-386-2534