Provider Demographics
NPI:1487090429
Name:PROVIDENCE PSYCHOLOGICAL SERVICES INC
Entity type:Organization
Organization Name:PROVIDENCE PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAWANNA
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC, CSOTP
Authorized Official - Phone:757-535-7839
Mailing Address - Street 1:129 N SARATOGA ST
Mailing Address - Street 2:STE 1
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5255
Mailing Address - Country:US
Mailing Address - Phone:757-539-5353
Mailing Address - Fax:757-539-5399
Practice Address - Street 1:129 N SARATOGA ST
Practice Address - Street 2:STE 1
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5255
Practice Address - Country:US
Practice Address - Phone:757-539-5353
Practice Address - Fax:757-539-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA090400075341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty