1417238338 NPI number — VIRTUS HEALTH, LLC

Table of content: (NPI 1417238338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417238338 NPI number — VIRTUS HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRTUS 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:
LOVELL GLASS BEHAVIOR THERAPY, DBA APPLIED BEHAVIOR HEALTH
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 Information

NPI Number:
1417238338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8237 VICELA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34240-1462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-217-9289
Provider Business Mailing Address Fax Number:
888-751-4019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
992 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33953-3868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-374-6662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PELKEY
Authorized Official First Name:
REILLY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VP DIRECTOR OF CLIENT SERVICES
Authorized Official Telephone Number:
561-312-3940

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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