Provider Demographics
NPI:1386022101
Name:SUPPORTED LIVING AND EMPLOYMENT SERVICES, INC.
Entity Type:Organization
Organization Name:SUPPORTED LIVING AND EMPLOYMENT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CELESTA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTGRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-869-8911
Mailing Address - Street 1:1111 S GLENSTONE AVE STE 3-100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-0397
Mailing Address - Country:US
Mailing Address - Phone:417-869-8911
Mailing Address - Fax:417-864-3087
Practice Address - Street 1:2885 W BATTLEFIELD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3952
Practice Address - Country:US
Practice Address - Phone:417-869-8911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCC01430115320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO853297406Medicaid