MEDICARE: ST. MARY'S HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	000228	AL

General Provider Information

NPI Number	:	1427167444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S HOME

Provider Business Mailing Address
First Line	:	4350 MOFFETT RD
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36618-1719
Country	:	US
Telephone Number	:	251-344-7733
Fax Number	:	251-344-9753

Provider Business Practice Location Address
First Line	:	4350 MOFFETT RD
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36618-1719
Country	:	US
Telephone Number	:	251-344-7733
Fax Number	:	251-344-9753

Authorized Official
Title or Position	:	ADMININSTRATOR
Name	:	MR. PHILLIP ANDREW WYNNE
Credential	:	MSW
Telephone Number	:	251-344-7733

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/22/2020

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Directions to “ST. MARY'S HOME ” Practice Location

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