MEDICARE: CLAUDY'S HOUSE FOR DEVELOPMENTALLY CHALLENGED ADULTS

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1518229384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAUDY'S HOUSE FOR DEVELOPMENTALLY CHALLENGED ADULTS

Provider Business Mailing Address
First Line	:	1321 ROWAN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-3033
Country	:	US
Telephone Number	:	214-826-0018
Fax Number	:

Provider Business Practice Location Address
First Line	:	1321 ROWAN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-3033
Country	:	US
Telephone Number	:	214-826-0018
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	MS. DONNA WILKINSON BRODEN
Credential	:	MA, CCC-SLP
Telephone Number	:	214-392-5776

Provider Enumeration Date	:	06/07/2012
Last Update Date	:	06/07/2012

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