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General NPI Number Information
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NPI Number | 1689165508
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Entity Type | Organization
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Legal Business Name | ENVISION BEHAVIORAL HEALTH PLLC
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Dates
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Enumeration Date | 05/25/2018
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Last Update Date | 06/10/2020
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Provider Practice Location Address
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Address Line | 2554 LEWISVILLE CLEMMONS RD STE 207
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City | CLEMMONS
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State | NC
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Zip | 27012-9752
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Country | US
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Telephone | 304-617-4337
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Fax | 339-207-0143
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Provider Business Mailing Address
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Address Line | 100 STADIUM OAKS DR STE B
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City | CLEMMONS
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State | NC
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Zip | 27012-8961
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JESSICA CIPOLETTI DERREBERRY
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Credential | MD
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Telephone | 304-617-4337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 2016-01870
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License Number State | NC
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