Provider Demographics
NPI:1043572886
Name:NEW RIVER BEHAVIORAL HEALTH AND ASSOCIATES,LLC
Entity type:Organization
Organization Name:NEW RIVER BEHAVIORAL HEALTH AND ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, QMHP
Authorized Official - Phone:276-223-0234
Mailing Address - Street 1:175 W MAIN ST STE 204
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2374
Mailing Address - Country:US
Mailing Address - Phone:276-223-0234
Mailing Address - Fax:276-223-0123
Practice Address - Street 1:175 W MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2374
Practice Address - Country:US
Practice Address - Phone:276-223-0234
Practice Address - Fax:276-223-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty