Provider Demographics
NPI:1235277237
Name:THE CHILDREN'S HOME, INC.
Entity Type:Organization
Organization Name:THE CHILDREN'S HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELING SERVICES MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDNES
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:BOULANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:813-855-4435
Mailing Address - Street 1:522 39TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5918
Mailing Address - Country:US
Mailing Address - Phone:727-822-6465
Mailing Address - Fax:
Practice Address - Street 1:10909 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2511
Practice Address - Country:US
Practice Address - Phone:813-855-4435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW6638322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767412100Medicaid