Provider Demographics
NPI:1700125374
Name:LILLITH MORRIS GROUP HOME INC.
Entity Type:Organization
Organization Name:LILLITH MORRIS GROUP HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSHUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-623-0404
Mailing Address - Street 1:364 SAN AMBROSIO ST
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-5767
Mailing Address - Country:US
Mailing Address - Phone:941-623-0404
Mailing Address - Fax:941-623-0404
Practice Address - Street 1:364 SAN AMBROSIO ST
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5767
Practice Address - Country:US
Practice Address - Phone:941-623-0404
Practice Address - Fax:941-623-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10001505320900000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689522196OtherMEDICAID PROVIDER # (DD WAIVER)