Provider Demographics
NPI:1598803124
Name:BOUNDLESS POTENTIAL LLC
Entity Type:Organization
Organization Name:BOUNDLESS POTENTIAL LLC
Other - Org Name:SISTER'S PLACE GROUP HOME I
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MALONE
Authorized Official - Last Name:RALPH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-901-3122
Mailing Address - Street 1:PO BOX 15238
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-0638
Mailing Address - Country:US
Mailing Address - Phone:804-261-5577
Mailing Address - Fax:804-261-5574
Practice Address - Street 1:1005 TELEGRAPH STATION LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-4006
Practice Address - Country:US
Practice Address - Phone:804-864-9001
Practice Address - Fax:804-864-9002
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOUNDLESS POTENTIAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VASS-04-09322D00000X
VASS-212-07322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00010231159Medicaid
VA008907757Medicaid