Healthcare Provider Details

I. General information

NPI: 1417975806
Provider Name (Legal Business Name): PSYCHOLOGICAL HEALTH ROANOKE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 ELECTRIC RD STE 200
ROANOKE VA
24018-3551
US

IV. Provider business mailing address

2840 ELECTRIC RD STE 200
ROANOKE VA
24018-3551
US

V. Phone/Fax

Practice location:
  • Phone: 540-777-7087
  • Fax: 540-772-5157
Mailing address:
  • Phone: 540-777-7087
  • Fax: 540-772-5157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: NANCY SANTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 540-777-7087