Provider Demographics
NPI:1619360013
Name:BORN TO BE GREAT II
Entity Type:Organization
Organization Name:BORN TO BE GREAT II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIA
Authorized Official - Middle Name:LATRESE
Authorized Official - Last Name:DEJOHNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:804-218-2088
Mailing Address - Street 1:19704 THELMA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2554
Mailing Address - Country:US
Mailing Address - Phone:804-218-2088
Mailing Address - Fax:
Practice Address - Street 1:3904 OLD HOPKINS RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-3037
Practice Address - Country:US
Practice Address - Phone:804-218-2088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA213416003251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management