Healthcare Provider Details

I. General information

NPI: 1801757562
Provider Name (Legal Business Name): PATRICK HENRY HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22840 PATRICK HENRY HWY
JETERSVILLE VA
23083-2803
US

IV. Provider business mailing address

22840 PATRICK HENRY HWY
JETERSVILLE VA
23083-2803
US

V. Phone/Fax

Practice location:
  • Phone: 410-353-8724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY WANDELOSKI
Title or Position: CREDENTIALING
Credential:
Phone: 410-353-8724