Provider Demographics
NPI:1306515812
Name:PRIME PSYCH VA, LLC
Entity type:Organization
Organization Name:PRIME PSYCH VA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:804-695-6633
Mailing Address - Street 1:1050 TEMPLE AVE # 524
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2981
Mailing Address - Country:US
Mailing Address - Phone:804-695-6633
Mailing Address - Fax:
Practice Address - Street 1:7751 SQUIRREL LEVEL RD
Practice Address - Street 2:
Practice Address - City:NORTH DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23803-7637
Practice Address - Country:US
Practice Address - Phone:804-695-6633
Practice Address - Fax:855-978-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043738206OtherNPI TYPE 1
VA0810005750OtherVA LCP ID#