Organization
BORN TO BE GREAT II
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MIA LATRESE DEJOHNETTE QMHP (EXECUTIVE DIRECTOR)
(804) 218-2088
Entity
Organization
Contact information
Practice address
3904 OLD HOPKINS RD, RICHMOND, VA 23234-3037
(804) 218-2088
Mailing address
19704 THELMA AVE, SOUTH CHESTERFIELD, VA 23803-2554
(804) 218-2088
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
213416003
VA
Other
Enumeration date
03/09/2015
Last updated
03/09/2015
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