Provider Demographics
NPI:1033779608
Name:WITH GREAT LOVE, LLC
Entity Type:Organization
Organization Name:WITH GREAT LOVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:314-920-1828
Mailing Address - Street 1:1203 US HIGHWAY 98 STE 2A9
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-3901
Mailing Address - Country:US
Mailing Address - Phone:314-920-1828
Mailing Address - Fax:251-243-0984
Practice Address - Street 1:1203 US HIGHWAY 98 STE 2A9
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-3901
Practice Address - Country:US
Practice Address - Phone:314-920-1828
Practice Address - Fax:251-243-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health