Provider Demographics
NPI:1366790107
Name:HAMLET HOUSE YOUTH SERVICES, III LLC
Entity type:Organization
Organization Name:HAMLET HOUSE YOUTH SERVICES, III LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:SCURLOCK
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-326-9046
Mailing Address - Street 1:517 CLAUSON RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1203
Mailing Address - Country:US
Mailing Address - Phone:804-326-9046
Mailing Address - Fax:
Practice Address - Street 1:206 CARLSTONE DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND SPRINGS
Practice Address - State:VA
Practice Address - Zip Code:23075-2503
Practice Address - Country:US
Practice Address - Phone:804-326-9046
Practice Address - Fax:804-326-9046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1347-14-001322D00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children