MEDICARE: DOMINION BEHAVIORAL HEALTHCARE OF CHESTERFIELD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	1041C0700X	Clinical Social Worker
3	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1831592898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION BEHAVIORAL HEALTHCARE OF CHESTERFIELD

Provider Business Mailing Address
First Line	:	703 N COURTHOUSE RD
Second Line	:	SUITE 101
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-4069
Country	:	US
Telephone Number	:	804-794-4482
Fax Number	:	804-379-7578

Provider Business Practice Location Address
First Line	:	703 N COURTHOUSE RD
Second Line	:	SUITE 101
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-4069
Country	:	US
Telephone Number	:	804-794-4482
Fax Number	:	804-379-7578

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. ROBERT SAMUEL FALK
Credential	:	PHD
Telephone Number	:	804-794-4482

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	10/06/2014

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