Provider Demographics
NPI:1558896993
Name:COUNCIL OF THE SOUTHERN MOUNTAINS
Entity Type:Organization
Organization Name:COUNCIL OF THE SOUTHERN MOUNTAINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-436-6800
Mailing Address - Street 1:148 MCDOWELL ST
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801-2225
Mailing Address - Country:US
Mailing Address - Phone:304-436-6800
Mailing Address - Fax:304-436-6803
Practice Address - Street 1:148 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2225
Practice Address - Country:US
Practice Address - Phone:304-436-6800
Practice Address - Fax:304-436-6803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV384251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health