Provider Demographics
NPI:1790017812
Name:ROANOKE VALLEY SPECIAL SERVICES LLC
Entity Type:Organization
Organization Name:ROANOKE VALLEY SPECIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BA
Authorized Official - Phone:252-536-0700
Mailing Address - Street 1:505 OLD HWY
Mailing Address - Street 2:
Mailing Address - City:GARYSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27831-0443
Mailing Address - Country:US
Mailing Address - Phone:252-536-0700
Mailing Address - Fax:252-536-0702
Practice Address - Street 1:505 OLD HWY
Practice Address - Street 2:
Practice Address - City:GARYSBURG
Practice Address - State:NC
Practice Address - Zip Code:27831-0443
Practice Address - Country:US
Practice Address - Phone:252-536-0700
Practice Address - Fax:252-536-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 104100000X, 106H00000X
NC6604101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301881Medicaid