Healthcare Provider Details

I. General information

NPI: 1730485905
Provider Name (Legal Business Name): SOUTHSIDE BEHAVIORAL HEALTH - HOPE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 CHARLOTTE AVE
LA CROSSE VA
23950-1703
US

IV. Provider business mailing address

PO BOX 1478 143 INDUSTRIAL PARKWAY
CLARKSVILLE VA
23927-1478
US

V. Phone/Fax

Practice location:
  • Phone: 434-447-4008
  • Fax: 434-447-4289
Mailing address:
  • Phone: 434-572-6916
  • Fax: 434-374-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

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