Provider Demographics
NPI:1518291418
Name:JUDEVINE, INC.
Entity Type:Organization
Organization Name:JUDEVINE, INC.
Other - Org Name:JUDEVINE CENTER FOR AUTISM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:800-780-6545
Mailing Address - Street 1:1810 CRAIG RD STE 109
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4758
Mailing Address - Country:US
Mailing Address - Phone:800-780-6545
Mailing Address - Fax:888-507-4453
Practice Address - Street 1:1810 CRAIG RD STE 109
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4758
Practice Address - Country:US
Practice Address - Phone:800-780-6545
Practice Address - Fax:888-507-4453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 252Y00000X, 253Z00000X
MOER019910064251S00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care