Provider Demographics
NPI:1225094451
Name:DISTRICT 19 COMMUNITY SERVICES BOARD
Entity Type:Organization
Organization Name:DISTRICT 19 COMMUNITY SERVICES BOARD
Other - Org Name:DISTRICT 19 MENTAL HEALTH AND MENTAL RETARDATION SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:804-862-8054
Mailing Address - Street 1:20 W BANK ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3279
Mailing Address - Country:US
Mailing Address - Phone:804-862-8054
Mailing Address - Fax:804-863-1665
Practice Address - Street 1:20 W BANK ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-862-8054
Practice Address - Fax:804-863-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945280Medicaid
VA4945280Medicaid
VA008504D13Medicare PIN
VA010331D13Medicare PIN
VA019421D13Medicare PIN
VA800002562Medicare PIN
VAC06113Medicare PIN
VA017112D13Medicare PIN
VA018450D13Medicare PIN
019262D13Medicare PIN
VAMC10055Medicare PIN
VA005784D13Medicare PIN
VA011451D13Medicare PIN
VA014211D13Medicare PIN
VA016457D13Medicare PIN
VA260003093Medicare PIN
VA019274D13Medicare PIN
VA800001808Medicare PIN
VAMC10059Medicare PIN