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General NPI Number Information
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NPI Number | 1780133280
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Entity Type | Organization
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Legal Business Name | ELITE PSYCHOTHERAPY AND BEHAVIORAL HEALTH SERVICES, LLC
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Dates
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Enumeration Date | 09/25/2016
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 612 HULL ST STE 101A
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City | RICHMOND
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State | VA
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Zip | 23224-4180
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Country | US
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Telephone | 804-351-5971
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Fax | 804-351-5972
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Provider Business Mailing Address
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Address Line | 3209 OAKINGTON DR
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City | RICHMOND
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State | VA
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Zip | 23231-7267
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Country | US
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Telephone | 804-677-0379
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Fax | 804-351-5972
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MS. TINA MARIE FOUNTAIN
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Credential | LCSW
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Telephone | 804-677-0379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904005723
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License Number State | VA
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