Healthcare Provider Details

I. General information

NPI: 1093362840
Provider Name (Legal Business Name): DEVARAJ BEHAVIORAL HEALTHCARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 TENNESSEE AVE
CHARLESTON WV
25302-2338
US

IV. Provider business mailing address

412 TENNESSEE AVE
CHARLESTON WV
25302-2338
US

V. Phone/Fax

Practice location:
  • Phone: 877-338-2725
  • Fax: 304-715-3537
Mailing address:
  • Phone: 877-338-2725
  • Fax: 304-715-3537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JACOB M BOUNDS
Title or Position: CLINICAL DIRECTOR
Credential: LGSW
Phone: 877-338-2725