=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750088274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MILIEU THERAPEUTIC SERVICES, ,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2023
-----------------------------------------------------
Last Update Date | 06/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1730 GEORGE WASHINGTON MEM HWY STE F-6
-----------------------------------------------------
City | YORKTOWN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23693-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-464-5438
-----------------------------------------------------
Fax | 757-578-8226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5007C VICTORY BLVD # 118
-----------------------------------------------------
City | YORKTOWN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23693-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-464-5438
-----------------------------------------------------
Fax | 757-578-8226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | WILLARD A VAUGHN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 833-464-5438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------