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General NPI Number Information
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NPI Number | 1932461852
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Entity Type | Organization
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Legal Business Name | NEW LEGACY YOUTH SERVICES, LLC
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Dates
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Enumeration Date | 06/15/2012
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Last Update Date | 06/15/2012
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Provider Practice Location Address
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Address Line | 904 NORTH 1ST STREET
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City | RICHMOND
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State | VA
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Zip | 23219
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Country | US
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Telephone | 804-479-5908
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Fax |
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Provider Business Mailing Address
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Address Line | 904 NORTH 1ST ST
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City | RICHMOND
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State | VA
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Zip | 23219-1000
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Country | US
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Telephone | 804-479-5908
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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 | KENDRICK KELLY
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Credential | QMHP
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Telephone | 804-479-5908
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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 | 1418
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License Number State | VA
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