Healthcare Provider Details

I. General information

NPI: 1013350552
Provider Name (Legal Business Name): IASIS COUNSELING AND CONSULTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4609 W BROAD ST SUITE A2
RICHMOND VA
23230-3205
US

IV. Provider business mailing address

1351 BLACKROCK DR
RICHMOND VA
23225-4101
US

V. Phone/Fax

Practice location:
  • Phone: 804-355-2333
  • Fax: 804-355-3540
Mailing address:
  • Phone: 804-882-6163
  • Fax: 804-355-3540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0701004328
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0701004328
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004328
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701004328
License Number StateVA

VIII. Authorized Official

Name: DR. THEA A GREEN
Title or Position: CEO
Credential: PH.D,, L.P.C.
Phone: 804-882-6163