Provider Demographics
NPI:1922141068
Name:WILLOW CREEK GROUP HOME, INC.
Entity Type:Organization
Organization Name:WILLOW CREEK GROUP HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-297-8956
Mailing Address - Street 1:RR 2 BOX 27
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MO
Mailing Address - Zip Code:64720-9587
Mailing Address - Country:US
Mailing Address - Phone:816-297-8956
Mailing Address - Fax:816-297-4032
Practice Address - Street 1:RR 2 BOX 27
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MO
Practice Address - Zip Code:64720-9587
Practice Address - Country:US
Practice Address - Phone:816-297-8956
Practice Address - Fax:816-297-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities