Healthcare Provider Details

I. General information

NPI: 1528091063
Provider Name (Legal Business Name): CROSSROADS SERVICES BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 BUSH RIVER DRIVE
FARMVILLE VA
23901
US

IV. Provider business mailing address

P.O. DRAWER 248
FARMVILLE VA
23901
US

V. Phone/Fax

Practice location:
  • Phone: 434-392-7049
  • Fax: 434-392-9221
Mailing address:
  • Phone: 434-392-7049
  • Fax: 434-392-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE FOORE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 434-392-7049