MEDICARE: CORNERSTONE SERVICE INTERVENTION SYSTEMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	915 05 001	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DMHMRSAS	OTHER	VA	LICENSE # 915 05 001

General Provider Information

NPI Number	:	1033321237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE SERVICE INTERVENTION SYSTEMS

Provider Business Mailing Address
First Line	:	4620 HAYGOOD RD STE 6
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-5401
Country	:	US
Telephone Number	:	757-464-2470
Fax Number	:

Provider Business Practice Location Address
First Line	:	4620 HAYGOOD RD STE 6
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-5401
Country	:	US
Telephone Number	:	757-464-2470
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. WALTER LEWIS STONE JR.
Credential	:	MS
Telephone Number	:	757-464-2470

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	11/22/2013

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