=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164669966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMONWEALTH PSYCHOLOGICAL SERVICES, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2009
-----------------------------------------------------
Last Update Date | 01/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2322 BLUE STONE HILL DR SUITE 280
-----------------------------------------------------
City | HARRISONBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22801-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-437-4820
-----------------------------------------------------
Fax | 540-437-4823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2322 BLUE STONE HILL DR SUITE 280
-----------------------------------------------------
City | HARRISONBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22801-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-437-4820
-----------------------------------------------------
Fax | 540-437-4823
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE COORDINATOR
-----------------------------------------------------
Name | MISS JESSICA LYNNE GALLARO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-437-4820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810003002
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------