Provider Demographics
NPI:1518591353
Name:ADVANCED BEHAVIORAL WELLNESS L.C.
Entity Type:Organization
Organization Name:ADVANCED BEHAVIORAL WELLNESS L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALEXANDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:434-207-2329
Mailing Address - Street 1:3401 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-5469
Mailing Address - Country:US
Mailing Address - Phone:434-207-2329
Mailing Address - Fax:
Practice Address - Street 1:3401 WESTOVER DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-5469
Practice Address - Country:US
Practice Address - Phone:434-207-2329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1477937787Medicaid