Provider Demographics
NPI:1891808036
Name:CHRYSALIS, A HOME FOR GIRLS, INC.
Entity Type:Organization
Organization Name:CHRYSALIS, A HOME FOR GIRLS, INC.
Other - Org Name:CHRYSALIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DISMUKES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:334-793-2237
Mailing Address - Street 1:100 WESTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1908
Mailing Address - Country:US
Mailing Address - Phone:334-793-2237
Mailing Address - Fax:334-712-6256
Practice Address - Street 1:545 JUDGE LOGUE RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:AL
Practice Address - Zip Code:36352-8607
Practice Address - Country:US
Practice Address - Phone:334-692-5553
Practice Address - Fax:334-692-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12901322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children