Basic Information
Provider Information | |||||||||
NPI: | 1508941105 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HORIZON BEHAVIORAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 620 COURT ST | ||||||||
Address2: |   | ||||||||
City: | LYNCHBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 245041312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4348478035 | ||||||||
FaxNumber: | 4344858877 | ||||||||
Practice Location | |||||||||
Address1: | 3410 OLD FOREST RD | ||||||||
Address2: |   | ||||||||
City: | LYNCHBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 245012915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4344555342 | ||||||||
FaxNumber: | 4344858877 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2006 | ||||||||
LastUpdateDate: | 04/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURNETT | ||||||||
AuthorizedOfficialFirstName: | JAMIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 4344555342 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 1508941105 | 05 | VA |   | MEDICAID | 010012350 | 05 | VA |   | MEDICAID |