=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700987419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPHA COUNSELING ASSO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2142 PLAINVIEW CENTER
-----------------------------------------------------
City | POWHATAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-598-9105
-----------------------------------------------------
Fax | 804-598-6379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 554
-----------------------------------------------------
City | POWHATAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-598-9105
-----------------------------------------------------
Fax | 804-598-6379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO PRESIDENT
-----------------------------------------------------
Name | MS. MARTY MONTGOMERY-JENNINGS
-----------------------------------------------------
Credential | MA LCSW
-----------------------------------------------------
Telephone | 804-598-9105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 0904005352
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------