Provider Demographics
NPI:1841413184
Name:DOMINION BEHAVIORAL HEALTHCARE
Entity Type:Organization
Organization Name:DOMINION BEHAVIORAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:Z
Authorized Official - Last Name:HENSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-270-1124
Mailing Address - Street 1:11551 NUCKOLS RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5565
Mailing Address - Country:US
Mailing Address - Phone:804-364-4400
Mailing Address - Fax:804-364-0120
Practice Address - Street 1:11551 NUCKOLS RD
Practice Address - Street 2:SUITE F
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5565
Practice Address - Country:US
Practice Address - Phone:804-364-4400
Practice Address - Fax:804-364-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X, 103T00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05599Medicare ID - Type UnspecifiedMEDICARE NUMBER