Provider Demographics
NPI:1053402800
Name:PRINCE WILLIAM COUNTY COMMUNITY SERVICES BOARD
Entity type:Organization
Organization Name:PRINCE WILLIAM COUNTY COMMUNITY SERVICES BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANSAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-792-7800
Mailing Address - Street 1:7969 ASHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2885
Mailing Address - Country:US
Mailing Address - Phone:703-792-7800
Mailing Address - Fax:703-792-5699
Practice Address - Street 1:7969 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2885
Practice Address - Country:US
Practice Address - Phone:703-792-7800
Practice Address - Fax:703-792-5699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004978277Medicaid
VA210245OtherBLUE CROSS BLUE SHIELD
VA004945247Medicaid
VA004945247Medicaid