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General NPI Number Information
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NPI Number | 1225368905
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Entity Type | Organization
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Legal Business Name | D.Y.V.I.N.E YOUTH SERVICES LLC
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Dates
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Enumeration Date | 01/02/2010
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Last Update Date | 01/02/2010
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Provider Practice Location Address
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Address Line | 6956 FOREST HILL AVE STE B
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City | RICHMOND
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State | VA
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Zip | 23225-1657
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Country | US
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Telephone | 804-562-4206
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Fax |
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Provider Business Mailing Address
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Address Line | 6956 FOREST HILL AVE STE B
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City | RICHMOND
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State | VA
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Zip | 23225-1657
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Country | US
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Telephone | 804-562-4206
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MISS NICOLE CAPRICE CULBRETH
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Credential | MHS
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Telephone | 804-267-0846
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 127905001
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License Number State | VA
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