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General NPI Number Information
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NPI Number | 1134477060
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Entity Type | Organization
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Legal Business Name | SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES
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Dates
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Enumeration Date | 08/27/2012
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Last Update Date | 04/12/2013
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Provider Practice Location Address
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Address Line | 142 W JACKSON ST SUITE 101
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City | GATE CITY
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State | VA
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Zip | 24251-2929
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Country | US
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Telephone | 276-386-2535
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Fax |
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Provider Business Mailing Address
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Address Line | 142 W JACKSON ST SUITE 101
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City | GATE CITY
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State | VA
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Zip | 24251-2929
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Country | US
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Telephone | 276-386-2535
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST/PART
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Name | DR. MICHAEL C MCDONOUGH
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Credential | LCP
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Telephone | 276-386-2534
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904004740
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2451
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License Number State | VA
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