Healthcare Provider Details

I. General information

NPI: 1033321237
Provider Name (Legal Business Name): CORNERSTONE SERVICE INTERVENTION SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 HAYGOOD RD STE 6
VIRGINIA BEACH VA
23455-5401
US

IV. Provider business mailing address

4620 HAYGOOD RD STE 6
VIRGINIA BEACH VA
23455-5401
US

V. Phone/Fax

Practice location:
  • Phone: 757-464-2470
  • Fax:
Mailing address:
  • Phone: 757-464-2470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number915 05 001
License Number StateVA

VIII. Authorized Official

Name: MR. WALTER LEWIS STONE JR.
Title or Position: DIRECTOR
Credential: MS
Phone: 757-464-2470