Provider Demographics
NPI:1093040214
Name:JAMES BENTLEY TREATMENT PROGRAM
Entity Type:Organization
Organization Name:JAMES BENTLEY TREATMENT PROGRAM
Other - Org Name:HAVEN HOUSE FOR GIRLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PINNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-399-4742
Mailing Address - Street 1:1020 LECKIE STRTEET
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704
Mailing Address - Country:US
Mailing Address - Phone:757-399-3742
Mailing Address - Fax:757-673-7965
Practice Address - Street 1:1020 LECKIE STREET
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704
Practice Address - Country:US
Practice Address - Phone:757-399-4742
Practice Address - Fax:757-675-7965
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAVEN HOUSE FOR GIRLS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA78214002320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA78214002Medicaid