Provider Demographics
NPI:1497232805
Name:HEATHERS OLD SKOOL VILLAGE
Entity Type:Organization
Organization Name:HEATHERS OLD SKOOL VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-236-8275
Mailing Address - Street 1:6018 GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3304
Mailing Address - Country:US
Mailing Address - Phone:817-236-8275
Mailing Address - Fax:817-236-8275
Practice Address - Street 1:6018 GRAHAM ST
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3304
Practice Address - Country:US
Practice Address - Phone:817-236-8275
Practice Address - Fax:817-236-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services