Provider Demographics
NPI:1215263629
Name:VILLAGE RESTORATION
Entity type:Organization
Organization Name:VILLAGE RESTORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:TRAVERS
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, EDS, LPC
Authorized Official - Phone:757-218-2507
Mailing Address - Street 1:PO BOX 15194
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-0023
Mailing Address - Country:US
Mailing Address - Phone:757-218-2507
Mailing Address - Fax:
Practice Address - Street 1:550 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4240
Practice Address - Country:US
Practice Address - Phone:757-218-2507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004205251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management