Provider Demographics
NPI:1831214386
Name:ROANOKE VALLEY SPECIAL SERVICES LLC
Entity type:Organization
Organization Name:ROANOKE VALLEY SPECIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR,MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BS, QP
Authorized Official - Phone:252-533-0045
Mailing Address - Street 1:PO BOX 1364
Mailing Address - Street 2:113 W 10TH STREET
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-1364
Mailing Address - Country:US
Mailing Address - Phone:252-533-0045
Mailing Address - Fax:252-533-0046
Practice Address - Street 1:113 W 10TH STREET
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-1364
Practice Address - Country:US
Practice Address - Phone:252-533-0045
Practice Address - Fax:252-533-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301881Medicaid