Healthcare Provider Details

I. General information

NPI: 1366810392
Provider Name (Legal Business Name): BELLWETHER BEHAVIORAL OF VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9932 MAIN ST
FAIRFAX VA
22031-3901
US

IV. Provider business mailing address

2520 WRANGLE HILL RD SUITE 200
BEAR DE
19701-3849
US

V. Phone/Fax

Practice location:
  • Phone: 302-365-8050
  • Fax:
Mailing address:
  • Phone: 302-365-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0701006290
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2666
License Number StateVA

VIII. Authorized Official

Name: KATHLEEN SHEA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 302-365-8050