Provider Demographics
NPI:1992879282
Name:MIDDLE PENINSULA-NORTHERN NECK MENTAL HEALTH AND MENTAL RETARDATION
Entity type:Organization
Organization Name:MIDDLE PENINSULA-NORTHERN NECK MENTAL HEALTH AND MENTAL RETARDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-758-5314
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SALUDA
Mailing Address - State:VA
Mailing Address - Zip Code:23149-0040
Mailing Address - Country:US
Mailing Address - Phone:804-758-5250
Mailing Address - Fax:804-758-5138
Practice Address - Street 1:5372B OLD VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175
Practice Address - Country:US
Practice Address - Phone:804-758-5250
Practice Address - Fax:804-758-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006727225100000X
VA2305002514225100000X
VA2202000605235Z00000X
VA2202002885235Z00000X
VA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4978137Medicaid
VA496521Medicare ID - Type UnspecifiedOUTPATIENT REHABILITATION