Provider Demographics
NPI:1417070210
Name:FAITH TABERNACLE WORLD OUTREACH INC
Entity Type:Organization
Organization Name:FAITH TABERNACLE WORLD OUTREACH INC
Other - Org Name:FAITH FOUNDATION CHILDREN'S HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:573-783-4400
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:FREDRICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645
Mailing Address - Country:US
Mailing Address - Phone:573-783-4400
Mailing Address - Fax:573-783-4409
Practice Address - Street 1:600 SARGENT DR
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-7526
Practice Address - Country:US
Practice Address - Phone:573-783-4400
Practice Address - Fax:573-783-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-08
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
MO001742092322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490026705Medicaid
MO495888919Medicaid
MO495933814Medicaid
MO495968604Medicaid