Healthcare Provider Details

I. General information

NPI: 1780135863
Provider Name (Legal Business Name): MOUNTAINEER BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3094 CHARLES TOWN ROAD
KEARNEYSVILLE WV
25430
US

IV. Provider business mailing address

3094 CHARLES TOWN ROAD
KEARNEYSVILLE WV
25430
US

V. Phone/Fax

Practice location:
  • Phone: 304-901-2070
  • Fax: 304-885-1054
Mailing address:
  • Phone: 304-901-2070
  • Fax: 304-885-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number443
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JASON HENDRICKS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 148-940-0407