Provider Demographics
NPI:1700890761
Name:SOUTHSIDE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:SOUTHSIDE BEHAVIORAL HEALTH
Other - Org Name:SOUTHSIDE COMMUNITY SERVICES BOARD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ENGELHORN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:434-572-6916
Mailing Address - Street 1:PO BOX 1478
Mailing Address - Street 2:143 INDUSTRIAL PARKWAY
Mailing Address - City:CLARKSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23927
Mailing Address - Country:US
Mailing Address - Phone:434-572-6916
Mailing Address - Fax:434-374-3321
Practice Address - Street 1:143 INDUSTRIAL PARKWAY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23927
Practice Address - Country:US
Practice Address - Phone:434-572-6916
Practice Address - Fax:434-374-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA090101YM0800X, 1041C0700X, 2084P0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945514Medicaid
VA1912252958Medicaid
VA1700890761Medicaid
VACC3355OtherMEDICARE RAILROAD
VA1700890761Medicaid
VAC05606Medicare PIN