Basic Information
Provider Information | |||||||||
NPI: | 1740700186 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED FAMILY INTERVENTIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1047 VISTA PARK DR STE A | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | VA | ||||||||
PostalCode: | 245514362 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4346162388 | ||||||||
FaxNumber: | 4346162344 | ||||||||
Practice Location | |||||||||
Address1: | 1047 VISTA PARK DR | ||||||||
Address2: | STE A | ||||||||
City: | FOREST | ||||||||
State: | VA | ||||||||
PostalCode: | 24551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4346162388 | ||||||||
FaxNumber: | 4346162344 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARCLAY | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4346162388 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 103TC0700X | 0810004569 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.