1194213918 NPI number — MATRIX BEHAVIORAL HEALTH PRACTICE LLC

Table of content: (NPI 1194213918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194213918 NPI number — MATRIX BEHAVIORAL HEALTH PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATRIX BEHAVIORAL HEALTH PRACTICE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MATRIX BEHAVIORAL HEALTH PRACTICE LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194213918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12137 DOGWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULPEPER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22701-1352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-260-9897
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 S BRADDOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22601-4090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-853-0959
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
RIDGEWAY
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
LEONA
Authorized Official Title or Position:
CEO/CLINICAL PRACTITIONER
Authorized Official Telephone Number:
803-260-9897

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  525 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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