Provider Demographics
NPI:1366857294
Name:AUTUMN HOUSE
Entity Type:Organization
Organization Name:AUTUMN HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE/UR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-612-3312
Mailing Address - Street 1:5511 STAPLES MILL RD
Mailing Address - Street 2:STE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5445
Mailing Address - Country:US
Mailing Address - Phone:804-440-3700
Mailing Address - Fax:
Practice Address - Street 1:1301 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5218
Practice Address - Country:US
Practice Address - Phone:804-440-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERCEPT YOUTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-30
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children