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General NPI Number Information
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NPI Number | 1104006055
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Entity Type | Organization
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Legal Business Name | HAMPTON ROADS YOUTH CENTER
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Dates
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Enumeration Date | 11/08/2007
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Last Update Date | 11/08/2007
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Provider Practice Location Address
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Address Line | 275 KENYON RD SUITE B
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City | SUFFOLK
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State | VA
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Zip | 23434-7450
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Country | US
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Telephone | 757-923-4948
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Fax | 757-923-4949
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Provider Business Mailing Address
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Address Line | 275 KENYON RD
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City | SUFFOLK
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State | VA
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Zip | 23434-7450
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Country | US
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Telephone | 757-923-4948
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Fax | 757-923-4949
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MRS. DENISE RAE MULLINS
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Credential | LCSW, CSAC
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Telephone | 757-923-4948
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | SS-241-06
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License Number State | VA
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