MEDICARE: PREMIER MENTAL HEALTH SUPPORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1477150068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER MENTAL HEALTH SUPPORT

Provider Business Mailing Address
First Line	:	490 PINEY FOREST RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-4060
Country	:	US
Telephone Number	:	434-797-1094
Fax Number	:	434-797-1096

Provider Business Practice Location Address
First Line	:	490 PINEY FOREST RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-4060
Country	:	US
Telephone Number	:	434-797-1094
Fax Number	:	434-797-1096

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	KIMBERLY HARPER GIBSON
Credential	:	RN
Telephone Number	:	434-728-2641

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

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