=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891040408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECT YOUTH AND FAMILY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2012
-----------------------------------------------------
Last Update Date | 07/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1158 PROFESSIONAL DR STE C
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-6618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-345-5240
-----------------------------------------------------
Fax | 757-345-5241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1158 PROFESSIONAL DR STE C
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-6618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-345-5240
-----------------------------------------------------
Fax | 757-345-5241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MRS. TERRI KEESEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-753-0563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1633
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------