MEDICARE: CHRYSALIS, A HOME FOR GIRLS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	12901	AL

General Provider Information

NPI Number	:	1891808036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRYSALIS, A HOME FOR GIRLS, INC.

Provider Business Mailing Address
First Line	:	100 WESTSIDE DR
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-1908
Country	:	US
Telephone Number	:	334-793-2237
Fax Number	:	334-712-6256

Provider Business Practice Location Address
First Line	:	545 JUDGE LOGUE RD
Second Line	:
City	:	NEWTON
State	:	AL
Zip	:	36352-8607
Country	:	US
Telephone Number	:	334-692-5553
Fax Number	:	334-692-5554

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. RICHARD DISMUKES
Credential	:	LPC
Telephone Number	:	334-793-2237

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	08/22/2020

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