Provider Demographics
NPI:1255507497
Name:MOUNTAIN LAKE CHILDREN'S RESIDENCE, INC.
Entity Type:Organization
Organization Name:MOUNTAIN LAKE CHILDREN'S RESIDENCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-523-4300
Mailing Address - Street 1:386 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946
Mailing Address - Country:US
Mailing Address - Phone:518-523-4300
Mailing Address - Fax:518-523-5322
Practice Address - Street 1:386 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946
Practice Address - Country:US
Practice Address - Phone:518-523-4300
Practice Address - Fax:518-523-5322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINDWOOD MEADOW, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-07
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01949242Medicaid