MEDICARE: PATHWAYS-VA, INC.

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	1041C0700X	Clinical Social Worker	LC301671	DC

General Provider Information

NPI Number	:	1467770859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAYS-VA, INC.

Provider Business Mailing Address
First Line	:	1200 W WASHINGTON ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-3923
Country	:	US
Telephone Number	:	804-862-1104
Fax Number	:	804-862-1015

Provider Business Practice Location Address
First Line	:	1200 W WASHINGTON ST
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-3923
Country	:	US
Telephone Number	:	804-862-1104
Fax Number	:	804-862-1015

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DWALA FERRELL
Credential	:
Telephone Number	:	804-862-1104

Provider Enumeration Date	:	05/10/2010
Last Update Date	:	05/10/2010

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