Provider Demographics
NPI:1023490711
Name:TRIPLE WILLOW MENTAL HEALTH CLINIC, INC
Entity type:Organization
Organization Name:TRIPLE WILLOW MENTAL HEALTH CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:DON
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, DCC
Authorized Official - Phone:804-781-4418
Mailing Address - Street 1:7300 HANOVER GREEN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-1705
Mailing Address - Country:US
Mailing Address - Phone:804-781-4418
Mailing Address - Fax:804-212-0981
Practice Address - Street 1:7300 HANOVER GREEN DR STE 100
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1705
Practice Address - Country:US
Practice Address - Phone:804-781-4418
Practice Address - Fax:804-212-0981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM0850X, 261QM0855X
VA0701006887101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health