Provider Demographics
NPI:1619078052
Name:INTERCEPT YOUTH SERVICES, INC.
Entity Type:Organization
Organization Name:INTERCEPT YOUTH SERVICES, INC.
Other - Org Name:FREDERICK HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMENCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-864-1320
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:804-864-1320
Mailing Address - Fax:804-864-1323
Practice Address - Street 1:5511 STAPLES MILL RD STE 102
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5445
Practice Address - Country:US
Practice Address - Phone:804-864-1320
Practice Address - Fax:804-864-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010220262Medicaid