MEDICARE: FAMILY BEHAVIORAL HEALTH ASSOCIATES, LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0015000796	VA
2	103TC0700X	Clinical Psychologist	0810000953	VA

General Provider Information

NPI Number	:	1932290624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY BEHAVIORAL HEALTH ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	5001 W VILLAGE GREEN DR
Second Line	:	SUITE 211
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4801
Country	:	US
Telephone Number	:	804-744-9652
Fax Number	:	804-744-1265

Provider Business Practice Location Address
First Line	:	5001 W VILLAGE GREEN DR
Second Line	:	SUITE 211
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-4801
Country	:	US
Telephone Number	:	804-744-9652
Fax Number	:	804-744-1265

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. WILLIAM T. BURKE
Credential	:	PH.D.
Telephone Number	:	804-744-9652

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	01/11/2013

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