Healthcare Provider Details

I. General information

NPI: 1588264626
Provider Name (Legal Business Name): PRIMARY ADDICTION TREATMENT CENTER (P.A.T.)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 OYSTER POINT RD STE D
NEWPORT NEWS VA
23602-6014
US

IV. Provider business mailing address

525 OYSTER POINT RD STE D
NEWPORT NEWS VA
23602-6014
US

V. Phone/Fax

Practice location:
  • Phone: 757-296-0444
  • Fax:
Mailing address:
  • Phone: 757-296-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DEMI DE LA VEGA
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 757-296-0444