Healthcare Provider Details

I. General information

NPI: 1700890761
Provider Name (Legal Business Name): SOUTHSIDE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 INDUSTRIAL PARKWAY
CLARKSVILLE VA
23927
US

IV. Provider business mailing address

PO BOX 1478 143 INDUSTRIAL PARKWAY
CLARKSVILLE VA
23927
US

V. Phone/Fax

Practice location:
  • Phone: 434-572-6916
  • Fax: 434-374-3321
Mailing address:
  • Phone: 434-572-6916
  • Fax: 434-374-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number090
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number090
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH C ENGELHORN
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 434-572-6916