Provider Demographics
NPI:1699868448
Name:MEMORIAL-CHILD-GUIDANCE-CLINIC
Entity type:Organization
Organization Name:MEMORIAL-CHILD-GUIDANCE-CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:HEIRHOLZER
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:804-644-0590
Mailing Address - Street 1:200 NORTH 22ND STREET
Mailing Address - Street 2:N/A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223
Mailing Address - Country:US
Mailing Address - Phone:804-644-9590
Mailing Address - Fax:804-649-2151
Practice Address - Street 1:200 NORTH 22ND STREET
Practice Address - Street 2:N/A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223
Practice Address - Country:US
Practice Address - Phone:804-644-9590
Practice Address - Fax:804-649-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA065101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945182Medicaid