Provider Demographics
NPI:1982333167
Name:SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES CORP
Entity type:Organization
Organization Name:SOUTHWEST VIRGINIA CHILD DEVELOPMENT SERVICES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICAHEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:276-386-2534
Mailing Address - Street 1:142 W JACKSON ST # 101
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-2929
Mailing Address - Country:US
Mailing Address - Phone:276-386-2534
Mailing Address - Fax:276-386-2535
Practice Address - Street 1:142 W JACKSON ST # 101
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-2929
Practice Address - Country:US
Practice Address - Phone:276-386-2534
Practice Address - Fax:276-386-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-06
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty