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General NPI Number Information
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NPI Number | 1467781799
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Entity Type | Organization
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Legal Business Name | YOUTH AND FAMILY DYNAMICS DAY TREATMENT SUPPORT,LLC
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Dates
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Enumeration Date | 12/16/2009
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Last Update Date | 12/03/2013
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Provider Practice Location Address
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Address Line | 5741 S LABURNUM AVE
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City | HENRICO
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State | VA
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Zip | 23231-4431
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Country | US
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Telephone | 804-501-9440
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Fax |
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Provider Business Mailing Address
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Address Line | 1733 FIRST COLONIAL CT
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City | HENRICO
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State | VA
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Zip | 23231-6892
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Country | US
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Telephone | 804-501-9440
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Fax |
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Authorized Official
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Title or Position | CHEIF EXECUTIVE OFFICER/LLC
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Name | MR. ALLEN F JACKSON JR.
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Credential |
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Telephone | 804-501-9440
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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 | 1162-02-030
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License Number State | VA
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