Organization Name: | WILLOW CREEK GROUP HOME |
NPI Number: | 1942544820 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | JEANIE SUE STEPHENS (OWNER) |
Mailing Address: | Rural Route 2, Box 27 Adrian |
State: | MO US |
Postal Code: | 64720 |
Phone Number: | 8162974256 |
Fax Number: | 8162978956 |
NPI Enumeration Date: | 11/16/2012 |
NPI Last Update Date: | 11/16/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 320900000X |
License Number: | WC2-0252-0712 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MO |
Taxonomy Type: | Residential Treatment Facilities |
Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
Taxonomy Specialization: | |
Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |