Provider Demographics
NPI:1790036820
Name:BRANCHES OF HOPE, LLC MENTAL HEALTH SUPPORT
Entity Type:Organization
Organization Name:BRANCHES OF HOPE, LLC MENTAL HEALTH SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-LICENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:276-632-3210
Mailing Address - Street 1:58 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-6210
Mailing Address - Country:US
Mailing Address - Phone:276-632-3210
Mailing Address - Fax:276-632-3213
Practice Address - Street 1:20 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2724
Practice Address - Country:US
Practice Address - Phone:276-632-3210
Practice Address - Fax:276-632-3213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRANCHES OF HOPE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-28
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1838-03-001Medicaid