Organization
SW VA PSYCHOLOGICAL SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN WALLACE LUDGATE PH.D (PRESIDENT)
(276) 628-5752
Entity
Organization
Contact information
Practice address
361B FALLS DR NW, ABINGDON, VA 24210-8093
(276) 628-5752
(276) 628-5190
Mailing address
PO BOX 245, ABINGDON, VA 24212-0245
(276) 628-5752
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
0810002165
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007703171
—
VA
Enumeration date
09/24/2008
Last updated
09/24/2008
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