Healthcare Provider Details

I. General information

NPI: 1679601280
Provider Name (Legal Business Name): BOUNDLESS POTENTIAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10204 SPINNING WHEEL WAY
RICHMOND VA
23233
US

IV. Provider business mailing address

P.O. BOX 15238
RICHMOND VA
23227-0638
US

V. Phone/Fax

Practice location:
  • Phone: 804-864-9001
  • Fax: 804-864-9002
Mailing address:
  • Phone: 804-290-0216
  • Fax: 804-290-0427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number287-2006
License Number StateVA

VIII. Authorized Official

Name: MRS. DEBORAH MALONE RALPH
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: L.C.S.W.
Phone: 804-901-3122