Provider Demographics
NPI:1407957822
Name:INTERCEPT YOUTH SERVICES, INC.
Entity Type:Organization
Organization Name:INTERCEPT YOUTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMENCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-864-1320
Mailing Address - Street 1:5511 STAPLES MILL RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5445
Mailing Address - Country:US
Mailing Address - Phone:804-864-1320
Mailing Address - Fax:804-864-1323
Practice Address - Street 1:11622 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2345
Practice Address - Country:US
Practice Address - Phone:757-643-6960
Practice Address - Fax:757-643-6962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
VA295-14-012322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010167078Medicaid
VA601028709Medicaid