=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215390380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL PARK BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2016
-----------------------------------------------------
Last Update Date | 12/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 THIMBLE SHOALS BLVD STE 202B
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-327-0203
-----------------------------------------------------
Fax | 757-327-0228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 THIMBLE SHOALS BLVD STE 202B
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-327-0203
-----------------------------------------------------
Fax | 757-903-0531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. PATRICE LAVONNE MATTHEWS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-469-0332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------