Basic Information
| Provider Information | |||||||||
| NPI: | 1689331209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILDREN'S HOME, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10909 MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138554435 | ||||||||
| FaxNumber: | 8138558640 | ||||||||
| Practice Location | |||||||||
| Address1: | 10909 MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138554435 | ||||||||
| FaxNumber: | 8138558640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2021 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7276882681 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CHILDREN'S HOME, INC. | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 023052400 | 05 | FL | MEDICAID |