MEDICARE: DOMINION BEHAVIORAL HEALTHCARE

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	101YM0800X	Mental Health Counselor	0904000405	VA

General Provider Information

NPI Number	:	1528086238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION BEHAVIORAL HEALTHCARE

Provider Business Mailing Address
First Line	:	6501 MECHANICSVILLE TPKE
Second Line	:	SUITE 100
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23111-3698
Country	:	US
Telephone Number	:	804-270-1124
Fax Number	:	804-270-2090

Provider Business Practice Location Address
First Line	:	6501 MECHANICSVILLE TPKE
Second Line	:	SUITE 100
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23111-3698
Country	:	US
Telephone Number	:	804-270-1124
Fax Number	:	804-270-2090

Authorized Official
Title or Position	:	OWNER
Name	:	MS. DIANNE ZITO HENSLEY
Credential	:	LCSW
Telephone Number	:	804-270-1124

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/09/2013

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