Healthcare Provider Details

I. General information

NPI: 1306515812
Provider Name (Legal Business Name): PRIME PSYCH VA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7751 SQUIRREL LEVEL RD
NORTH DINWIDDIE VA
23803-7637
US

IV. Provider business mailing address

1050 TEMPLE AVE # 524
COLONIAL HEIGHTS VA
23834-2981
US

V. Phone/Fax

Practice location:
  • Phone: 804-695-6633
  • Fax: 855-978-2324
Mailing address:
  • Phone: 804-695-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. FRANK ROBERT ROSE
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 804-695-6633