=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194356931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAY TO DAY RESPITE AND REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2020
-----------------------------------------------------
Last Update Date | 01/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 HOUSTON ST
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-371-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 HOUSTON ST
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-371-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | AMANDA S JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 936-371-1536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------