Provider Demographics
NPI:1093891699
Name:CITY OF PORTSMOUTH
Entity Type:Organization
Organization Name:CITY OF PORTSMOUTH
Other - Org Name:DEPARTMENT OF BEHAVIORAL HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/PROGRAM SPONSOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BREATHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:M ED,CSAC,QMHP,QSAP
Authorized Official - Phone:757-393-8618
Mailing Address - Street 1:1811 KING STREET
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3032
Mailing Address - Country:US
Mailing Address - Phone:757-393-5404
Mailing Address - Fax:757-393-5405
Practice Address - Street 1:1811 KING STREET
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3032
Practice Address - Country:US
Practice Address - Phone:757-393-5404
Practice Address - Fax:757-393-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA046251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945204Medicaid
VA004945204Medicaid