Provider Demographics
NPI:1285801928
Name:IMPACT YOUTH SERVICES, LLC
Entity type:Organization
Organization Name:IMPACT YOUTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:LOUREEN
Authorized Official - Last Name:CADET
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:804-301-9624
Mailing Address - Street 1:14507 GLENMORGAN DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-6638
Mailing Address - Country:US
Mailing Address - Phone:804-301-9624
Mailing Address - Fax:804-454-0243
Practice Address - Street 1:6725 CASEY SAVANNAH LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-8013
Practice Address - Country:US
Practice Address - Phone:804-301-9624
Practice Address - Fax:804-454-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA88314001320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness