Healthcare Provider Details

I. General information

NPI: 1366790107
Provider Name (Legal Business Name): HAMLET HOUSE YOUTH SERVICES, III LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 CARLSTONE DR
HIGHLAND SPRINGS VA
23075-2503
US

IV. Provider business mailing address

517 CLAUSON RD
RICHMOND VA
23227-1203
US

V. Phone/Fax

Practice location:
  • Phone: 804-326-9046
  • Fax: 804-326-9046
Mailing address:
  • Phone: 804-326-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number1347-14-001
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number1347-14-001
License Number StateVA

VIII. Authorized Official

Name: MRS. GWENDOLYN SCURLOCK INGRAM
Title or Position: CHIEF ADMINISTRATIVE OFFICE
Credential:
Phone: 804-326-9046