Healthcare Provider Details

I. General information

NPI: 1437871753
Provider Name (Legal Business Name): MARY'S HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 PORTSMOUTH BLVD
CHESAPEAKE VA
23321-2126
US

IV. Provider business mailing address

4020 PORTSMOUTH BLVD
CHESAPEAKE VA
23321-2126
US

V. Phone/Fax

Practice location:
  • Phone: 757-529-8844
  • Fax:
Mailing address:
  • Phone: 757-529-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL CLANTON
Title or Position: CEO
Credential:
Phone: 757-529-8844