Provider Demographics
NPI:1467765198
Name:LIFE YOUNG ADULT SERVICES, LLC
Entity Type:Organization
Organization Name:LIFE YOUNG ADULT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEMBERLY
Authorized Official - Middle Name:LILES
Authorized Official - Last Name:RAINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LSATP
Authorized Official - Phone:804-248-6964
Mailing Address - Street 1:6013 MANOR HOUSE TRL
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-2248
Mailing Address - Country:US
Mailing Address - Phone:804-248-6964
Mailing Address - Fax:804-279-0702
Practice Address - Street 1:3105 W MARSHALL ST
Practice Address - Street 2:SUITE 208-212
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-4729
Practice Address - Country:US
Practice Address - Phone:804-658-1096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health