Healthcare Provider Details

I. General information

NPI: 1992714398
Provider Name (Legal Business Name): POTOMAC HIGHLANDS MENTAL HEALTH GUILD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PARK ST
PETERSBURG WV
26847-1765
US

IV. Provider business mailing address

6 PARK ST
PETERSBURG WV
26847-1765
US

V. Phone/Fax

Practice location:
  • Phone: 304-257-1155
  • Fax: 304-257-1945
Mailing address:
  • Phone: 304-257-1155
  • Fax: 304-257-1945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number14000
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number14000
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1036-8848
License Number StateWV

VIII. Authorized Official

Name: MR. S. CRAIG CURTIS
Title or Position: CEO
Credential:
Phone: 304-257-1155