Provider Demographics
NPI:1417136466
Name:HAMPTON ROADS YOUTH CENTER
Entity Type:Organization
Organization Name:HAMPTON ROADS YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:757-923-4948
Mailing Address - Street 1:275 KENYON RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-7450
Mailing Address - Country:US
Mailing Address - Phone:757-923-4948
Mailing Address - Fax:757-923-4949
Practice Address - Street 1:275 KENYON RD
Practice Address - Street 2:SUITE A
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-7450
Practice Address - Country:US
Practice Address - Phone:757-923-4948
Practice Address - Fax:757-923-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VASS-241-06322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children