=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023658242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNASTY COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 11/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2807 N PARHAM RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23294-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-426-3405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2807 N PARHAM RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23294-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-426-3405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. TREVON KEONTE BURCH
-----------------------------------------------------
Credential | B.S. QMHP
-----------------------------------------------------
Telephone | 804-426-3405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------