Provider Demographics
NPI:1255493805
Name:PALMER SPRINGS GROUP HOME INC
Entity type:Organization
Organization Name:PALMER SPRINGS GROUP HOME INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KITTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-689-2113
Mailing Address - Street 1:2450 MINERAL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917-4404
Mailing Address - Country:US
Mailing Address - Phone:434-689-2113
Mailing Address - Fax:434-689-3328
Practice Address - Street 1:2453 MINERAL SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917-4404
Practice Address - Country:US
Practice Address - Phone:434-689-2113
Practice Address - Fax:434-689-3328
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMER SPRINGS GROUP HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 251S00000X
VA837-01-001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health