Provider Demographics
NPI:1679674329
Name:INTERCEPT YOUTH SERVICES, INC.
Entity Type:Organization
Organization Name:INTERCEPT YOUTH SERVICES, INC.
Other - Org Name:INDEPENDENCE HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIR OF ACCOUNTING & ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:GRAHAM
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 1:3111 N PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4408
Practice Address - Country:US
Practice Address - Phone:804-270-7056
Practice Address - Fax:804-270-7057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA295-14-003322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010075599Medicaid