Provider Demographics
NPI:1932461852
Name:NEW LEGACY YOUTH SERVICES, LLC
Entity Type:Organization
Organization Name:NEW LEGACY YOUTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:804-479-5908
Mailing Address - Street 1:904 NORTH 1ST ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-1000
Mailing Address - Country:US
Mailing Address - Phone:804-479-5908
Mailing Address - Fax:
Practice Address - Street 1:904 NORTH 1ST STREET
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219
Practice Address - Country:US
Practice Address - Phone:804-479-5908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1418251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health