Provider Demographics
NPI:1780135863
Name:MOUNTAINEER BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:MOUNTAINEER BEHAVIORAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:148-940-0407
Mailing Address - Street 1:3094 CHARLES TOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:KEARNEYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25430
Mailing Address - Country:US
Mailing Address - Phone:304-901-2070
Mailing Address - Fax:304-885-1054
Practice Address - Street 1:3094 CHARLES TOWN ROAD
Practice Address - Street 2:
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430
Practice Address - Country:US
Practice Address - Phone:304-901-2070
Practice Address - Fax:304-885-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV443251S00000X
261QR0405X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV443OtherDEPARTMENT OF HEALTH AND HUMAN RESOURCES BEHAVIORAL HEALTH LICENSE