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General NPI Number Information
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NPI Number | 1619360013
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Entity Type | Organization
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Legal Business Name | BORN TO BE GREAT II
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Dates
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Enumeration Date | 03/09/2015
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Last Update Date | 03/09/2015
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Provider Practice Location Address
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Address Line | 3904 OLD HOPKINS RD
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City | RICHMOND
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State | VA
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Zip | 23234-3037
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Country | US
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Telephone | 804-218-2088
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Fax |
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Provider Business Mailing Address
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Address Line | 19704 THELMA AVE
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City | SOUTH CHESTERFIELD
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State | VA
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Zip | 23803-2554
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Country | US
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Telephone | 804-218-2088
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MIA LATRESE DEJOHNETTE
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Credential | QMHP
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Telephone | 804-218-2088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 213416003
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License Number State | VA
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