Provider Demographics
NPI:1538250311
Name:PRINCE, PAUL EDMOND SR (PH D)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDMOND
Last Name:PRINCE
Suffix:SR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11881 WEXWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236
Mailing Address - Country:US
Mailing Address - Phone:804-379-0266
Mailing Address - Fax:
Practice Address - Street 1:810 WESTWOOD OFFICE PARK RACDC
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5121
Practice Address - Country:US
Practice Address - Phone:540-899-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002371103TC0700X, 103TC2200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service