Provider Demographics
NPI:1558808329
Name:INTERCEPT YOUTH SERVICES
Entity Type:Organization
Organization Name:INTERCEPT YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CLINICAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-724-2256
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:
Mailing Address - Fax:
Practice Address - Street 1:5511 STAPLES MILL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5445
Practice Address - Country:US
Practice Address - Phone:804-440-3711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children