Provider Demographics
NPI:1720281264
Name:MOUNT PROSPECT ACADEMY, INC.
Entity Type:Organization
Organization Name:MOUNT PROSPECT ACADEMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:T
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-353-9102
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:ORFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03777-0325
Mailing Address - Country:US
Mailing Address - Phone:603-353-9102
Mailing Address - Fax:603-353-9412
Practice Address - Street 1:350 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-4518
Practice Address - Country:US
Practice Address - Phone:603-536-1102
Practice Address - Fax:603-536-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30854897Medicaid
NH30832240Medicaid