Healthcare Provider Details

I. General information

NPI: 1629421946
Provider Name (Legal Business Name): CENTRAL VIRGINIA BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 N 24TH ST
RICHMOND VA
23223-5232
US

IV. Provider business mailing address

1213 N 24TH ST
RICHMOND VA
23223-5232
US

V. Phone/Fax

Practice location:
  • Phone: 804-263-6403
  • Fax:
Mailing address:
  • Phone: 804-263-6403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001731
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001731
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number001731
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number001731
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001731
License Number StateVA

VIII. Authorized Official

Name: MRS. C NICOLE SIMMONS-JACKSON
Title or Position: CAO
Credential: MSW
Phone: 804-263-6403