Basic Information
| Provider Information | |||||||||
| NPI: | 1902342934 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRINCE WILLIAM COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8033 ASHTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201092895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037927800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7762 DONEGAN DR | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201092868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037924935 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2017 | ||||||||
| LastUpdateDate: | 01/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | WOOTEN | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7037927894 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 0904000578 | VA | Y | Agencies | Community/Behavioral Health |
No ID Information.