Healthcare Provider Details

I. General information

NPI: 1730926916
Provider Name (Legal Business Name): SOAR BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2024
Last Update Date: 07/13/2024
Certification Date: 07/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 FLUME RUN APT 102
NEWPORT NEWS VA
23602-8900
US

IV. Provider business mailing address

700 FLUME RUN APT 102
NEWPORT NEWS VA
23602-8900
US

V. Phone/Fax

Practice location:
  • Phone: 478-595-3400
  • Fax:
Mailing address:
  • Phone: 478-595-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN W AHAVA
Title or Position: PSYCHOLOGIST/SOLE MEMBER
Credential: PH.D.
Phone: 478-595-3400