Provider Demographics
NPI:1346000320
Name:SOUTHERN SUPPORT BEHAVIORAL HEALTH CARE LLC
Entity Type:Organization
Organization Name:SOUTHERN SUPPORT BEHAVIORAL HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-642-5345
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:COLERAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27924-0134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9840 MIDLOTHIAN TPKE STE J
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4864
Practice Address - Country:US
Practice Address - Phone:252-209-7896
Practice Address - Fax:877-225-6011
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN SUPPORT BEHAVIORAL HEALTH CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health