Healthcare Provider Details

I. General information

NPI: 1689445884
Provider Name (Legal Business Name): EAST RIVER PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WESTWOOD CMN
BLUEFIELD VA
24605-2031
US

IV. Provider business mailing address

105 WESTWOOD CMN
BLUEFIELD VA
24605-2031
US

V. Phone/Fax

Practice location:
  • Phone: 276-235-6232
  • Fax: 276-250-5117
Mailing address:
  • Phone: 276-235-6232
  • Fax: 276-250-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: HOLLY DISIBBIO
Title or Position: EMPLOYEE
Credential: NP
Phone: 301-904-3804