Provider Demographics
NPI:1770607384
Name:VIRGINIA DARE BEHAVORIAL HEALTH SERVICES INC.
Entity type:Organization
Organization Name:VIRGINIA DARE BEHAVORIAL HEALTH SERVICES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:MAXINE
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-238-2622
Mailing Address - Street 1:367 LANE ROAD
Mailing Address - Street 2:
Mailing Address - City:STANTONSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27883
Mailing Address - Country:US
Mailing Address - Phone:252-238-2622
Mailing Address - Fax:252-238-6566
Practice Address - Street 1:367 LANE ROAD
Practice Address - Street 2:
Practice Address - City:STANTONSBURG
Practice Address - State:NC
Practice Address - Zip Code:27883
Practice Address - Country:US
Practice Address - Phone:252-238-2622
Practice Address - Fax:252-238-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL040016305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301320Medicaid
NC7805104Medicaid
NC3409231Medicaid