Provider Demographics
NPI:1770146540
Name:MIDLAND VALLEY BEHAVIORAL HEALTH & CONSULTING, LLC
Entity type:Organization
Organization Name:MIDLAND VALLEY BEHAVIORAL HEALTH & CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:EARLES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:803-380-9004
Mailing Address - Street 1:388 BRIDLE PATH RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9085
Mailing Address - Country:US
Mailing Address - Phone:803-640-5101
Mailing Address - Fax:803-369-3240
Practice Address - Street 1:3524 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829
Practice Address - Country:US
Practice Address - Phone:803-380-9004
Practice Address - Fax:803-369-3240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health