=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043344229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADISON COUNTY COUNCIL FOR DEVELOPMENTALLY DISABLED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 S CHAMBER DR
-----------------------------------------------------
City | FREDERICKTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63645-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-783-3770
-----------------------------------------------------
Fax | 573-783-5051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 S CHAMBER DR
-----------------------------------------------------
City | FREDERICKTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63645-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-783-3770
-----------------------------------------------------
Fax | 573-783-5051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KATHERINE LAWLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-783-3770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 1603-9524
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------