Provider Demographics
NPI:1235511692
Name:GREEN MAXVILLE SUPPORTIVE LIVING LLC
Entity Type:Organization
Organization Name:GREEN MAXVILLE SUPPORTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAXVILLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD, BCBA-D, LBA
Authorized Official - Phone:573-864-9743
Mailing Address - Street 1:5900 GALLI LN
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-5836
Mailing Address - Country:US
Mailing Address - Phone:573-864-9743
Mailing Address - Fax:573-874-1713
Practice Address - Street 1:101 E ALHAMBRA DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3763
Practice Address - Country:US
Practice Address - Phone:573-864-9743
Practice Address - Fax:573-874-1723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health