=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023187200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL YOUTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4136 WOODFIELD RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-3450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-674-4456
-----------------------------------------------------
Fax | 804-674-4458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7206 HULL STREET RD SUITE 102A
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-674-4460
-----------------------------------------------------
Fax | 804-674-4480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHEIF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. JEMARN BERNARD THORPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-674-4460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------