Healthcare Provider Details

I. General information

NPI: 1720281264
Provider Name (Legal Business Name): MOUNT PROSPECT ACADEMY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 MAIN ST
PLYMOUTH NH
03264-4518
US

IV. Provider business mailing address

PO BOX 325
ORFORD NH
03777-0325
US

V. Phone/Fax

Practice location:
  • Phone: 603-536-1102
  • Fax: 603-536-3074
Mailing address:
  • Phone: 603-353-9102
  • Fax: 603-353-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAY T WOLTER
Title or Position: PRESIDENT
Credential:
Phone: 603-353-9102