1205643764 NPI number — CHANNEL BEHAVIORAL CARE VA LLC

Table of content: (NPI 1205643764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205643764 NPI number — CHANNEL BEHAVIORAL CARE VA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANNEL BEHAVIORAL CARE VA 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:
1205643764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7202 FORT HAMILTON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11228-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-238-4930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 W WASHINGTON ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434-5320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-238-4930
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2024

Additional Information

Authorized Official

Authorized Official Last Name:
SILBERMAN
Authorized Official First Name:
SIMCHA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
646-238-4930

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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