Healthcare Provider Details

I. General information

NPI: 1245014836
Provider Name (Legal Business Name): MID-ATLANTIC BEHAVIORAL SERVICES , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11923 CENTRE ST STE B1
CHESTER VA
23831-1702
US

IV. Provider business mailing address

11923 CENTRE ST STE B1
CHESTER VA
23831-1702
US

V. Phone/Fax

Practice location:
  • Phone: 310-270-0968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ITALIA TALLEY
Title or Position: OWNER
Credential:
Phone: 310-270-0968