Provider Demographics
NPI:1114238375
Name:OTL COMMUNITY SERVICES
Entity Type:Organization
Organization Name:OTL COMMUNITY SERVICES
Other - Org Name:GOOD NEIGHBOR MENTAL HEALTH SUPPORT, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HAILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-520-4600
Mailing Address - Street 1:9201 ARBORETUM PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-5407
Mailing Address - Country:US
Mailing Address - Phone:855-355-7001
Mailing Address - Fax:804-251-0989
Practice Address - Street 1:9201 ARBORETUM PKWY STE 300
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-5407
Practice Address - Country:US
Practice Address - Phone:855-355-7001
Practice Address - Fax:804-251-0989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA748-03-002251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA748-03-002OtherDEPARTMENT OF BEHAVIORAL HEALTH AND DISABILITY SERVICES