1588724850 NPI number — COUNSELING ASSOCIATES OF WYTHEVILLE, LLC

Table of content: DENISE R ADDIS (NPI 1144795410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588724850 NPI number — COUNSELING ASSOCIATES OF WYTHEVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNSELING ASSOCIATES OF WYTHEVILLE, 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:
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:
1588724850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 E MAIN ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
WYTHEVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24382-2328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-223-4443
Provider Business Mailing Address Fax Number:
276-223-0133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 E 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:
24382-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-223-4443
Provider Business Practice Location Address Fax Number:
276-223-0133
Provider Enumeration Date:
12/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
MARY
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
LICENSED PROFESSIONAL COUNSELOR
Authorized Official Telephone Number:
276-223-4443

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0701001401 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 0717000805 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 039925 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2237697 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 423453 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O-86315 . This is a "SENTARA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: VA0101 . This is a "UBH, JOHN DEERE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 023882 . This is a "VMC BEHAVIORAL SERVICES" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 222129 . This is a "PHCS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 343697 . This is a "MHN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 423453 . This is a "ALLIANCE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O-86315 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O-86315 . This is a "QUALCHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 32272 . This is a "MHN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7805017 . This is a "AETNA USHEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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