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General NPI Number Information
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NPI Number | 1043572886
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Entity Type | Organization
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Legal Business Name | NEW RIVER BEHAVIORAL HEALTH AND ASSOCIATES,LLC
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Dates
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Enumeration Date | 06/07/2012
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Last Update Date | 06/07/2012
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Provider Practice Location Address
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Address Line | 175 W MAIN ST STE 204
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City | WYTHEVILLE
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State | VA
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Zip | 24382-2374
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Country | US
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Telephone | 276-223-0234
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Fax | 276-223-0123
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Provider Business Mailing Address
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Address Line | 175 W MAIN ST STE 204
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City | WYTHEVILLE
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State | VA
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Zip | 24382-2374
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Country | US
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Telephone | 276-223-0234
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Fax | 276-223-0123
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Authorized Official
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Title or Position | CEO
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Name | MR. ROBERT ERNEST WALLACE
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Credential | MS, QMHP
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Telephone | 276-223-0234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1758
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License Number State | VA
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