MBHS OF KENBRIDGE, LLC (KENBRIDGE YOUTH ACADEMY) - NPI NUMBER 1972940880

Summary

Provider Name: MBHS OF KENBRIDGE, LLC (KENBRIDGE YOUTH ACADEMY)

NPI Number: 1972940880

Clasification: Clinic/Center (261QM0855X)

Specialization: Adolescent and Children Mental Health

Address:
231 HICKORY RD
KENBRIDGE, VA
ZIP 23944

Phone Number: (454) 676-1378



Detailed Information

MBHS OF KENBRIDGE, LLC is an adolescent and children mental health clinic/center in Kenbridge, VA. The provider is an entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to mental and behavioral disorders in children and adolescents. Services may be provided to parents and family members of the patient in the form of conjoint, group, or individual therapy, and education and/or training. The assigned NPI number for this provider is 1972940880 and is registered as an organization entity type.
The provider Is Doing Business As Kenbridge Youth Academy.

The provider's business address is:

231 HICKORY RD
KENBRIDGE, VA
ZIP 23944-503
Phone: (454) 676-1378

The provider's authorized official is Patricia Hamilton .
The authorized official title is Chief Administrative Officer and has the following contact phone number (454) 676-1378.

The enumeration date for this NPI number is 5/31/2013 and was last updated on 6/6/2013.

Map - Location of Practice

Similar Providers

NPI Provider Name / Taxonomy
1184838062 SOUTHERN DOMINION HEALTH SYSTEM, INC.
Clinic/Center (Federally Qualified Health Center (FQHC))
1760421010 KENBRIDGE FAMILY MEDICINE INC
Clinic/Center (Rural Health)

Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 261QM0855X Clinic/Center Adolescent and Children Mental Health 2139 VA No
2 322D00000X Residential Treatment Facility, Emotionally Disturbed Children 2136-14-001 VA Yes

NPI Record

No. Field Name Field Value
1 NPI 1972940880
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name MBHS OF KENBRIDGE, LLC
5 Provider Other Organization Name KENBRIDGE YOUTH ACADEMY
6 Provider Other Organization Name Type Code 3
7 Provider First Line Business Practice Location Address 231 HICKORY RD
8 Provider Business Practice Location Address City Name KENBRIDGE
9 Provider Business Practice Location Address State Name VA
10 Provider Business Practice Location Address Postal Code 239443503
11 Provider Business Practice Location Address Country Code If outside U S US
12 Provider Business Practice Location Address Telephone Number 4546761378
13 Provider Enumeration Date 5/31/2013
14 Last Update Date 6/6/2013
15 Authorized Official Last Name HAMILTON
16 Authorized Official First Name PATRICIA
17 Authorized Official Title or Position CHIEF ADMINISTRATIVE OFFICER
18 Authorized Official Telephone Number 4546761378
19 Healthcare Provider Taxonomy Code 1 261QM0855X
20 Provider License Number 1 2139
21 Provider License Number State Code 1 VA
22 Healthcare Provider Primary Taxonomy Switch 1 N
23 Healthcare Provider Taxonomy Code 2 322D00000X
24 Provider License Number 2 2136-14-001
25 Provider License Number State Code 2 VA
26 Healthcare Provider Primary Taxonomy Switch 2 Y
27 Is Organization Subpart Y
28 Parent Organization LBN MERIDIAN BEHAVIORAL HEALTH SYSTEMS
29 Parent Organization TIN

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This page was last updated on: 3/11/2014
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