Provider Demographics
NPI:1497717615
Name:MIDDLE PENINSULA NORTHERN NECK MENTAL HEALTH & RETARDATION
Entity Type:Organization
Organization Name:MIDDLE PENINSULA NORTHERN NECK MENTAL HEALTH & RETARDATION
Other - Org Name:MIDDLE PENINSULA NORTHERN NECK COUNSELING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WINGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:804-693-5640
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:ARK
Mailing Address - State:VA
Mailing Address - Zip Code:23003-0269
Mailing Address - Country:US
Mailing Address - Phone:804-693-5640
Mailing Address - Fax:804-693-4822
Practice Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4162
Practice Address - Country:US
Practice Address - Phone:804-693-5068
Practice Address - Fax:804-693-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497717615Medicaid
VA294721OtherVALUE OPTIONS
VA250204OtherANTHEM
VA250208OtherANTHEM
VA004945115Medicaid
VA250202OtherANTHEM
VA=========OtherTRICARE
VA=========OtherCIGNA
VA294721OtherVALUE OPTIONS
VAC03181Medicare ID - Type UnspecifiedMEDICARE