Healthcare Provider Details

I. General information

NPI: 1770607384
Provider Name (Legal Business Name): VIRGINIA DARE BEHAVORIAL HEALTH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 LANE ROAD
STANTONSBURG NC
27883
US

IV. Provider business mailing address

367 LANE ROAD
STANTONSBURG NC
27883
US

V. Phone/Fax

Practice location:
  • Phone: 252-238-2622
  • Fax: 252-238-6566
Mailing address:
  • Phone: 252-238-2622
  • Fax: 252-238-6566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberMHL040016
License Number StateNC

VIII. Authorized Official

Name: MISS PHYLLIS MAXINE WARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-238-2622