Healthcare Provider Details

I. General information

NPI: 1174662720
Provider Name (Legal Business Name): WOODRIDGE OF MISSOURI, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HOSPITAL ROAD
WAYNESVILLE MO
65583-4067
US

IV. Provider business mailing address

2520 NORTHWINDS PKWY STE 550
ALPHARETTA GA
30009-2236
US

V. Phone/Fax

Practice location:
  • Phone: 573-774-5353
  • Fax: 573-774-2907
Mailing address:
  • Phone: 470-554-7903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number000380592
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number30888669
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number3088-11051
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number000380592
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number000380592
License Number StateMO

VIII. Authorized Official

Name: ROCHELLE GERBER
Title or Position: AVP OF ADMINISTRATIVE SERVICES
Credential:
Phone: 470-554-7903