Healthcare Provider Details

I. General information

NPI: 1932290624
Provider Name (Legal Business Name): FAMILY BEHAVIORAL HEALTH ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 W VILLAGE GREEN DR SUITE 211
MIDLOTHIAN VA
23112-4801
US

IV. Provider business mailing address

5001 W VILLAGE GREEN DR SUITE 211
MIDLOTHIAN VA
23112-4801
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-9652
  • Fax: 804-744-1265
Mailing address:
  • Phone: 804-744-9652
  • Fax: 804-744-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810000953
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0015000796
License Number StateVA

VIII. Authorized Official

Name: DR. WILLIAM T. BURKE
Title or Position: MANAGING PARTNER
Credential: PH.D.
Phone: 804-744-9652