Provider Demographics
NPI:1891221065
Name:GLADYS B HOUSE, LLC
Entity Type:Organization
Organization Name:GLADYS B HOUSE, LLC
Other - Org Name:GLADYS B HOUSE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-528-6979
Mailing Address - Street 1:12875 SW 280TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032
Mailing Address - Country:US
Mailing Address - Phone:813-528-6979
Mailing Address - Fax:
Practice Address - Street 1:12875 SW 280TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032
Practice Address - Country:US
Practice Address - Phone:813-528-6979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No347C00000XTransportation ServicesPrivate Vehicle
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1891221065Medicaid