Provider Demographics
NPI:1528184736
Name:WILLOW BROOKE HOMES
Entity Type:Organization
Organization Name:WILLOW BROOKE HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSIST. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATTHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-456-2375
Mailing Address - Street 1:1903 STACY RD
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-3574
Mailing Address - Country:US
Mailing Address - Phone:816-380-2143
Mailing Address - Fax:
Practice Address - Street 1:1903 STACY RD
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-3574
Practice Address - Country:US
Practice Address - Phone:816-380-2143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services