Provider Demographics
NPI:1467725234
Name:REBECCA MAE FORBES
Entity Type:Organization
Organization Name:REBECCA MAE FORBES
Other - Org Name:BLUE MOON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-521-4500
Mailing Address - Street 1:130 45TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49026-9502
Mailing Address - Country:US
Mailing Address - Phone:269-521-4500
Mailing Address - Fax:
Practice Address - Street 1:130 45TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:MI
Practice Address - Zip Code:49026-9502
Practice Address - Country:US
Practice Address - Phone:269-521-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS030265913320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities