Healthcare Provider Details

I. General information

NPI: 1639201080
Provider Name (Legal Business Name): LACLEDE ASSOCIATION FOR DEVELOPMENTAL DISABILITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 05/26/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LAWSON AVENUE
LEBANON MO
65536
US

IV. Provider business mailing address

200 LAWSON AVENUE
LEBANON MO
65536
US

V. Phone/Fax

Practice location:
  • Phone: 417-588-1577
  • Fax: 417-588-3519
Mailing address:
  • Phone: 417-588-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number852755701
License Number StateMO

VIII. Authorized Official

Name: KATY CLANTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 417-588-1577