1215270467 NPI number — WYTHE WELLBEING, EMOTIONAL AND BEHAVIORAL HEALTH, LLC

Table of content: (NPI 1215270467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215270467 NPI number — WYTHE WELLBEING, EMOTIONAL AND BEHAVIORAL HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYTHE WELLBEING, EMOTIONAL AND BEHAVIORAL HEALTH, 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:
Provider Other Organization Name Type Code:
6
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:
1215270467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
469 SHARITZ RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYTHEVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24382-4671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-546-8388
Provider Business Mailing Address Fax Number:
276-546-8733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WYTHEVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24382-2376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-546-8388
Provider Business Practice Location Address Fax Number:
276-546-8733
Provider Enumeration Date:
04/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
IHRIG
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
REY
Authorized Official Title or Position:
THERAPIST/ CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
276-546-8388

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  VA0904005700 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1598731853 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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