1649209990 NPI number — DICKENSON COUNTY BEHAVIORAL HEALTH SERVICES

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649209990 NPI number — DICKENSON COUNTY BEHAVIORAL HEALTH SERVICES

Employer Identification Number (EIN):

Provider Organization Name:

DICKENSON COUNTY BEHAVIORAL HEALTH SERVICES

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

DICKENSON COUNTY COMMUNITY SERVICES BOARD

Provider Other Organization Name Type Code:

4

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:

1649209990

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

02/28/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 309

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CLINTWOOD

Provider Business Mailing Address State Name:

VA

Provider Business Mailing Address Postal Code:

24228-0309

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

276-926-1682

Provider Business Mailing Address Fax Number:

276-926-8134

Provider First Line Business Practice Location Address:

440 FOX TOWN RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CLINTWOOD

Provider Business Practice Location Address State Name:

VA

Provider Business Practice Location Address Postal Code:

24228-5077

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

276-926-1682

Provider Business Practice Location Address Fax Number:

276-926-9179

Provider Enumeration Date:

06/30/2006

Authorized Official Last Name:

MULLINS

Authorized Official First Name:

KEVIN

Authorized Official Middle Name:

Authorized Official Title or Position:

EXECUTIVE DIRECTOR

Authorized Official Telephone Number:

276-926-1682

• Taxonomy code: 101YM0800X , with the licence number:  091-07-004 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 251B00000X , with the licence number: 091-16-001 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QM0801X , with the licence number: 091-16-001 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 320600000X , with the licence number: 091-01-001 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 542636 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 004945549 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 542631 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 324879 . This is a "TRIGON" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 385241 . This is a "TRIGON" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".