Healthcare Provider Details

I. General information

NPI: 1144376112
Provider Name (Legal Business Name): BACON STREET YOUTH AND FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 MCLAWS CIRCLE
WILLIAMSBURG VA
23185
US

IV. Provider business mailing address

247 MCLAWS CIRCLE
WILLIAMSBURG VA
23185
US

V. Phone/Fax

Practice location:
  • Phone: 757-253-0111
  • Fax: 757-253-2884
Mailing address:
  • Phone: 757-253-0111
  • Fax: 757-253-2884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number254-07-004
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. APRIL WHALEN
Title or Position: BILLING SPECIALIST
Credential:
Phone: 757-253-0111