Provider Demographics
NPI:1811176092
Name:CHRYSALIS SCHOOL
Entity type:Organization
Organization Name:CHRYSALIS SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:406-889-5575
Mailing Address - Street 1:57 TRAILS END RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-9332
Mailing Address - Country:US
Mailing Address - Phone:406-889-5577
Mailing Address - Fax:
Practice Address - Street 1:57 TRAILS END RD
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-9332
Practice Address - Country:US
Practice Address - Phone:406-889-5577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL233169322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children