Provider Demographics
NPI:1053874370
Name:108 COUNSELING, LLC
Entity type:Organization
Organization Name:108 COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-221-2042
Mailing Address - Street 1:8710 CHOCTAW RD STE 6A
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-3472
Mailing Address - Country:US
Mailing Address - Phone:646-256-5103
Mailing Address - Fax:
Practice Address - Street 1:8710 CHOCTAW RD STE 6A
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3472
Practice Address - Country:US
Practice Address - Phone:646-256-5103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1366985228Medicaid