Healthcare Provider Details

I. General information

NPI: 1376728949
Provider Name (Legal Business Name): DIAMONDS IN THE ROUGH YOUTH AND FAMILY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FITZHUGH AVE., STE. 200
RICHMOND VA
23230-3531
US

IV. Provider business mailing address

P O BOX 6386
RICHMOND VA
23230-3531
US

V. Phone/Fax

Practice location:
  • Phone: 804-213-0140
  • Fax: 804-213-0143
Mailing address:
  • Phone: 804-213-0140
  • Fax: 804-213-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number464-05-001
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number464-14-001
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number464-14-001
License Number StateVA

VIII. Authorized Official

Name: MS. STEPHANIE LYNN DIXON
Title or Position: ADMINISTRATOR
Credential:
Phone: 804-213-0140