Provider Demographics
NPI:1649209990
Name:DICKENSON COUNTY BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:DICKENSON COUNTY BEHAVIORAL HEALTH SERVICES
Other - Org Name:DICKENSON COUNTY COMMUNITY SERVICES BOARD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:276-926-1682
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-0309
Mailing Address - Country:US
Mailing Address - Phone:276-926-1682
Mailing Address - Fax:276-926-8134
Practice Address - Street 1:440 FOX TOWN RD
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228-5077
Practice Address - Country:US
Practice Address - Phone:276-926-1682
Practice Address - Fax:276-926-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA091-07-004101YM0800X
VA091-16-001251B00000X, 261QM0801X
251C00000X, 261QM0801X
VA091-01-001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA542636OtherVALUE OPTIONS
VA004945549Medicaid
VA542631OtherVALUE OPTIONS
VA324879OtherTRIGON
VA385241OtherTRIGON
VA324879OtherTRIGON