{
"Npi": {
"NPI": "1306515812",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PRIME PSYCH VA, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1050 TEMPLE AVE # 524",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "COLONIAL HEIGHTS",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23834-2981",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "804-695-6633",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "7751 SQUIRREL LEVEL RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "NORTH DINWIDDIE",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23803-7637",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "804-695-6633",
"PracticeLocationAddressFaxNumber": "855-978-2324",
"EnumerationDate": "09/08/2021",
"LastUpdateDate": "09/30/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ROSE",
"AuthorizedOfficialFirstName": "FRANK",
"AuthorizedOfficialMiddleName": "ROBERT",
"AuthorizedOfficialTitle": "LICENSED CLINICAL PSYCHOLOGIST",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PSYD",
"AuthorizedOfficialTelephoneNumber": "804-695-6633",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0855X",
"TaxonomyName": "Adolescent and Children Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}