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General NPI Number Information
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NPI Number | 1396078069
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Entity Type | Organization
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Legal Business Name | PROVIDENCE CONSULTING AND CLINICAL SERVICES
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Dates
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Enumeration Date | 09/14/2009
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Last Update Date | 09/14/2009
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Provider Practice Location Address
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Address Line | 1000 REGENT UNIVERSITY DR CRB 161
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-5037
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Country | US
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Telephone | 757-348-8680
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Fax |
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Provider Business Mailing Address
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Address Line | 1989 BLUE KNOB RD
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-7435
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Country | US
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Telephone | 757-348-8680
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK A YARHOUSE
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Credential | PSY.D.
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Telephone | 757-348-8680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0810000366
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License Number State | VA
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