Provider Demographics
NPI:1104523968
Name:RESTORE BEHAVIORAL SERVICES LLC.
Entity type:Organization
Organization Name:RESTORE BEHAVIORAL SERVICES LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-509-4984
Mailing Address - Street 1:PO BOX 9112
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23670-0112
Mailing Address - Country:US
Mailing Address - Phone:757-509-4984
Mailing Address - Fax:
Practice Address - Street 1:1919 COMMERCE DR STE 230
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-4269
Practice Address - Country:US
Practice Address - Phone:757-509-4894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty