Healthcare Provider Details

I. General information

NPI: 1184930463
Provider Name (Legal Business Name): ABUNDANT LIFE CENTER IIH & MHSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 BONNIEBANK RD #304
RICHMOND VA
23234
US

IV. Provider business mailing address

4222 BONNIEBANK RD #304
RICHMOND VA
23234
US

V. Phone/Fax

Practice location:
  • Phone: 804-399-7108
  • Fax: 804-293-0857
Mailing address:
  • Phone: 804-399-7108
  • Fax: 804-293-0857

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number895-03-001
License Number StateVA

VIII. Authorized Official

Name: MRS. TONYA DENISE PRINCE
Title or Position: OWNER
Credential: MSW
Phone: 804-399-7108