1013210178 NPI number — YOUTH AND FAMILY DYNAMICS MENTAL HEALTH SUPPORT, LLC

Table of content: (NPI 1013210178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013210178 NPI number — YOUTH AND FAMILY DYNAMICS MENTAL HEALTH SUPPORT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUTH AND FAMILY DYNAMICS MENTAL HEALTH SUPPORT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013210178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1733 FIRST COLONIAL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENRICO
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23231-6892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-501-9440
Provider Business Mailing Address Fax Number:
804-222-8122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5741 S LABURNUM AVE
Provider Second Line Business Practice Location Address:
SUITE #111
Provider Business Practice Location Address City Name:
HENRICO
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23231-4431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-477-3065
Provider Business Practice Location Address Fax Number:
804-477-3092
Provider Enumeration Date:
12/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
CHEIF EXECUTIVE OFFICER
Authorized Official Telephone Number:
804-477-3065

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  1162 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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