Provider Demographics
NPI:1689165508
Name:ENVISION BEHAVIORAL HEALTH PLLC
Entity Type:Organization
Organization Name:ENVISION BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:CIPOLETTI
Authorized Official - Last Name:DERREBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-617-4337
Mailing Address - Street 1:100 STADIUM OAKS DR STE B
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 207
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9752
Practice Address - Country:US
Practice Address - Phone:304-617-4337
Practice Address - Fax:339-207-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-018702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty