Provider Demographics
NPI:1083878839
Name:BOYS AND GIRLS TOWN OF MISSOURI
Entity Type:Organization
Organization Name:BOYS AND GIRLS TOWN OF MISSOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ALFAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PLPC
Authorized Official - Phone:573-265-3251
Mailing Address - Street 1:13160 COUNTY RD 3610
Mailing Address - Street 2:
Mailing Address - City:ST. JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559
Mailing Address - Country:US
Mailing Address - Phone:573-265-3251
Mailing Address - Fax:
Practice Address - Street 1:13160 COUNTY RD 3610
Practice Address - Street 2:
Practice Address - City:ST. JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559
Practice Address - Country:US
Practice Address - Phone:573-265-3251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008015070320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008015070Medicaid