Healthcare Provider Details

I. General information

NPI: 1114690047
Provider Name (Legal Business Name): GRACE YOUTH MENTORING AND COMMUNITY OUTREACH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 DENBIGH BLVD STE A
NEWPORT NEWS VA
23608-4240
US

IV. Provider business mailing address

558 DENBIGH BLVD STE A
NEWPORT NEWS VA
23608-4240
US

V. Phone/Fax

Practice location:
  • Phone: 757-218-1918
  • Fax: 757-210-4021
Mailing address:
  • Phone: 757-218-1918
  • Fax: 757-210-4021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHARLENE NEWSOME
Title or Position: PRESIDENT
Credential:
Phone: 757-344-3450