Provider Demographics
NPI:1053847285
Name:CHESTNUT HILL MENTAL HEALTH CENTER, INC
Entity type:Organization
Organization Name:CHESTNUT HILL MENTAL HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:BURLESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-834-8013
Mailing Address - Street 1:1 HAVENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-9447
Mailing Address - Country:US
Mailing Address - Phone:864-834-8013
Mailing Address - Fax:
Practice Address - Street 1:1 HAVENWOOD LN
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-9447
Practice Address - Country:US
Practice Address - Phone:864-834-8013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103K00000X, 106E00000X, 106S00000X, 133N00000X, 133V00000X, 207R00000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC119917Medicaid
SC119917Medicaid