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General NPI Number Information
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NPI Number | 1114056074
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Entity Type | Organization
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Legal Business Name | INDIANA DEVELOPMENTAL TRAINING CENTER OF LAFAYETTE LLC
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3700 ROME DRIVE
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City | LAFAYETTE
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State | IN
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Zip | 47905
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Country | US
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Telephone | 765-448-4220
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Fax | 765-488-4217
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Provider Business Mailing Address
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Address Line | PO BOX 278
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City | DOUSMAN
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State | WI
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Zip | 53118
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MS. M DEBORAH FRISK
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Credential | MSW
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Telephone | 262-569-5515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | IN
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