Basic Information
| Provider Information | |||||||||
| NPI: | 1235277237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILDREN'S HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 522 39TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337035918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278226465 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10909 MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138554435 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOULANGER | ||||||||
| AuthorizedOfficialFirstName: | SANDNES | ||||||||
| AuthorizedOfficialMiddleName: | SMITH | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELING SERVICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8138554435 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | SW6638 | FL | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 767412100 | 05 | FL | MEDICAID |