Healthcare Provider Details

I. General information

NPI: 1699868448
Provider Name (Legal Business Name): MEMORIAL-CHILD-GUIDANCE-CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH 22ND STREET N/A
RICHMOND VA
23223
US

IV. Provider business mailing address

200 NORTH 22ND STREET N/A
RICHMOND VA
23223
US

V. Phone/Fax

Practice location:
  • Phone: 804-644-9590
  • Fax: 804-649-2151
Mailing address:
  • Phone: 804-644-9590
  • Fax: 804-649-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number065
License Number StateVA

VIII. Authorized Official

Name: MR. MARK N/A HEIRHOLZER
Title or Position: EXECUTIVE DIRECTOR
Credential: N/A
Phone: 804-644-0590