=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538529334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUTH TO WISDOM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2016
-----------------------------------------------------
Last Update Date | 03/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 WHITE CEDAR LN
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-5449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-690-8177
-----------------------------------------------------
Fax | 804-745-7183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 WHITE CEDAR LN
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-5449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-690-8177
-----------------------------------------------------
Fax | 804-745-7183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VOLUNTEER ADMINISTRATOR
-----------------------------------------------------
Name | MS. MARY BROWN BROOKS
-----------------------------------------------------
Credential | ADVOCATE
-----------------------------------------------------
Telephone | 804-690-8177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 1401112429
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------