Healthcare Provider Details

I. General information

NPI: 1861604134
Provider Name (Legal Business Name): MEMORIAL CHILD GUIDANCE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N 22ND ST
RICHMOND VA
23223-7020
US

IV. Provider business mailing address

200 N 22ND ST
RICHMOND VA
23223-7020
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number065-07-004
License Number StateVA

VIII. Authorized Official

Name: MARK HIERHOLZER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 804-644-9590