Provider Demographics
NPI:1790080760
Name:CHANGING FACES YOUTH SERVICES, LLC
Entity Type:Organization
Organization Name:CHANGING FACES YOUTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-479-1184
Mailing Address - Street 1:1413 IDLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-6003
Mailing Address - Country:US
Mailing Address - Phone:804-353-2397
Mailing Address - Fax:804-353-2022
Practice Address - Street 1:4410 CLAIBORNE SQ E
Practice Address - Street 2:SUITE 200
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2071
Practice Address - Country:US
Practice Address - Phone:804-353-2397
Practice Address - Fax:804-353-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1403-05-001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health