Provider Demographics
NPI:1225368905
Name:D.Y.V.I.N.E YOUTH SERVICES LLC
Entity Type:Organization
Organization Name:D.Y.V.I.N.E YOUTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:CAPRICE
Authorized Official - Last Name:CULBRETH
Authorized Official - Suffix:
Authorized Official - Credentials:MHS
Authorized Official - Phone:804-267-0846
Mailing Address - Street 1:6956 FOREST HILL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-1657
Mailing Address - Country:US
Mailing Address - Phone:804-562-4206
Mailing Address - Fax:
Practice Address - Street 1:6956 FOREST HILL AVE STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1657
Practice Address - Country:US
Practice Address - Phone:804-562-4206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-02
Last Update Date:2010-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA127905001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health