Basic Information
| Provider Information | |||||||||
| NPI: | 1194394981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC BEHAVIORAL HEALTH SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 LIBERTY ST SW | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201752715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036217121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 199 LIBERTY ST SW | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201752715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036217121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2021 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | VAZZANA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7036217121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATLANTIC COUNSELING GROUP | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.