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General NPI Number Information
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NPI Number | 1467765198
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Entity Type | Organization
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Legal Business Name | LIFE YOUNG ADULT SERVICES, LLC
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Dates
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Enumeration Date | 07/22/2010
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Last Update Date | 07/22/2010
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Provider Practice Location Address
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Address Line | 3105 W MARSHALL ST SUITE 208-212
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City | RICHMOND
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State | VA
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Zip | 23230-4729
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Country | US
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Telephone | 804-658-1096
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Fax |
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Provider Business Mailing Address
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Address Line | 6013 MANOR HOUSE TRL
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City | MOSELEY
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State | VA
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Zip | 23120-2248
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Country | US
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Telephone | 804-248-6964
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Fax | 804-279-0702
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Authorized Official
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Title or Position | VICE PRESIDENT/COO
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Name | MRS. KEMBERLY LILES RAINNEY
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Credential | L.P.C., L.S.A.T.P.
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Telephone | 804-248-6964
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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 |
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License Number State |
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