Provider Demographics
NPI:1295753630
Name:PRINCE, MICHAEL S (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:PRINCE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S LYNNHAVEN ROAD
Mailing Address - Street 2:STE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6664
Mailing Address - Country:US
Mailing Address - Phone:757-306-4232
Mailing Address - Fax:757-306-4235
Practice Address - Street 1:512 S LYNNHAVEN ROAD
Practice Address - Street 2:STE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6664
Practice Address - Country:US
Practice Address - Phone:757-306-4232
Practice Address - Fax:757-306-4235
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040031301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009999981Medicaid
C06310Medicare UPIN