Provider Demographics
NPI:1679601280
Name:BOUNDLESS POTENTIAL, LLC
Entity type:Organization
Organization Name:BOUNDLESS POTENTIAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MALONE
Authorized Official - Last Name:RALPH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-901-3122
Mailing Address - Street 1:P.O. BOX 15238
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-0638
Mailing Address - Country:US
Mailing Address - Phone:804-290-0216
Mailing Address - Fax:804-290-0427
Practice Address - Street 1:10204 SPINNING WHEEL WAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233
Practice Address - Country:US
Practice Address - Phone:804-864-9001
Practice Address - Fax:804-864-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA287-2006322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008907757Medicaid
VA008907759Medicaid
VA00010231159Medicaid