Provider Demographics
NPI:1972093987
Name:YOUTH CONNECT OF VIRGINIA, INC.
Entity Type:Organization
Organization Name:YOUTH CONNECT OF VIRGINIA, INC.
Other - Org Name:YOUTH CONNECT OF VA
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-488-5636
Mailing Address - Street 1:PO BOX 1104
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-8104
Mailing Address - Country:US
Mailing Address - Phone:540-488-5636
Mailing Address - Fax:
Practice Address - Street 1:370 TANYARD RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151
Practice Address - Country:US
Practice Address - Phone:540-488-5636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601363955Medicaid