=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811967813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENSIVE SUPERVISION AND COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 986 JOHN MARSHALL HWY UNIT D
-----------------------------------------------------
City | FRONT ROYAL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22630-4506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-636-0068
-----------------------------------------------------
Fax | 540-635-4006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 986 JOHN MARSHALL HWY UNIT D
-----------------------------------------------------
City | FRONT ROYAL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22630-4506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-636-0068
-----------------------------------------------------
Fax | 540-635-4006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. CHRISTIAN ROUSSEAU
-----------------------------------------------------
Credential | MA, QMHP
-----------------------------------------------------
Telephone | 540-636-0068
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 448
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------