Provider Demographics
NPI:1922123454
Name:ESTELLE PLACE LLC
Entity Type:Organization
Organization Name:ESTELLE PLACE LLC
Other - Org Name:OUR PLACE ONE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROUNDTREE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:703-221-9929
Mailing Address - Street 1:17964 SWANS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-4526
Mailing Address - Country:US
Mailing Address - Phone:703-221-9929
Mailing Address - Fax:703-221-9919
Practice Address - Street 1:16206 KINGS VALLEY DR
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22025-1738
Practice Address - Country:US
Practice Address - Phone:703-680-4428
Practice Address - Fax:703-221-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA755-02-006251C00000X
VA755-01-001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities