Provider Demographics
NPI:1083393086
Name:HERITAGE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:HERITAGE BEHAVIORAL HEALTH LLC
Other - Org Name:HERITAGE BEHAVIORAL HEALTH, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LASHAWNDA
Authorized Official - Middle Name:DELETRICE
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-532-6792
Mailing Address - Street 1:139 W CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23663-2203
Mailing Address - Country:US
Mailing Address - Phone:757-532-6792
Mailing Address - Fax:
Practice Address - Street 1:139 W CUMMINGS AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23663-2203
Practice Address - Country:US
Practice Address - Phone:757-532-6792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities