Provider Demographics
NPI:1528228079
Name:STRUCTURES YOUTH HOME INC
Entity Type:Organization
Organization Name:STRUCTURES YOUTH HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FITZSIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:540-663-0574
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:DAHLGREN
Mailing Address - State:VA
Mailing Address - Zip Code:22448-0149
Mailing Address - Country:US
Mailing Address - Phone:540-663-0574
Mailing Address - Fax:540-663-0576
Practice Address - Street 1:646 HOLLY CORNER RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-5308
Practice Address - Country:US
Practice Address - Phone:540-752-0013
Practice Address - Fax:540-752-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VASS-149-05320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness