Provider Demographics
NPI:1720819667
Name:MLC BEHAVIOR SERVICES
Entity type:Organization
Organization Name:MLC BEHAVIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:MONTALVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-662-1901
Mailing Address - Street 1:4785 ALICIA DR APT 208
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3811
Mailing Address - Country:US
Mailing Address - Phone:470-662-1901
Mailing Address - Fax:
Practice Address - Street 1:2200 COLONIAL AVE STE 16
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1934
Practice Address - Country:US
Practice Address - Phone:470-662-1901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health