=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598803124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOUNDLESS POTENTIAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2007
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 TELEGRAPH STATION LN
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23060-4006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-864-9001
-----------------------------------------------------
Fax | 804-864-9002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15238
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23227-0638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-261-5577
-----------------------------------------------------
Fax | 804-261-5574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CLINICAL SERVICES
-----------------------------------------------------
Name | MRS. DEBORAH MALONE RALPH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 804-901-3122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | SS-212-07
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | SS-04-09
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------