Provider Demographics
NPI:1043467285
Name:CAGLE, BETTY ANN
Entity Type:Individual
Prefix:MISS
First Name:BETTY
Middle Name:ANN
Last Name:CAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ST. THOMAS LANE
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869
Mailing Address - Country:US
Mailing Address - Phone:573-748-9438
Mailing Address - Fax:
Practice Address - Street 1:131 ST. THOMAS LANE
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869
Practice Address - Country:US
Practice Address - Phone:573-748-9438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2606 10125320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities