Provider Demographics
NPI:1093362840
Name:DEVARAJ BEHAVIORAL HEALTHCARE PLLC
Entity Type:Organization
Organization Name:DEVARAJ BEHAVIORAL HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:LGSW
Authorized Official - Phone:877-338-2725
Mailing Address - Street 1:1109 JEFFERSON RD STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-8815
Mailing Address - Country:US
Mailing Address - Phone:877-338-2725
Mailing Address - Fax:304-715-3537
Practice Address - Street 1:1109 JEFFERSON RD STE C
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8815
Practice Address - Country:US
Practice Address - Phone:877-338-2725
Practice Address - Fax:304-715-3537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-26
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty