Healthcare Provider Details

I. General information

NPI: 1083878839
Provider Name (Legal Business Name): BOYS AND GIRLS TOWN OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 COUNTY RD 3610
ST. JAMES MO
65559
US

IV. Provider business mailing address

13160 COUNTY RD 3610
ST. JAMES MO
65559
US

V. Phone/Fax

Practice location:
  • Phone: 573-265-3251
  • Fax:
Mailing address:
  • Phone: 573-265-3251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number2008015070
License Number StateMO

VIII. Authorized Official

Name: MS. ALFAYE JACKSON
Title or Position: THERAPIST
Credential: PLPC
Phone: 573-265-3251