=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255822375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A VILLAGE YOUTH & FAMILY SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2018
-----------------------------------------------------
Last Update Date | 05/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 PINEY FOREST RD STE 302D
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-2869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-264-7760
-----------------------------------------------------
Fax | 804-225-0753
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025 E MAIN ST STE 104
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23223-7072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 42-250-7498
-----------------------------------------------------
Fax | 804-225-0753
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KHIDHRA SMITH POOLE
-----------------------------------------------------
Credential | LCSW, DSW
-----------------------------------------------------
Telephone | 804-225-0749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------