Provider Demographics
NPI:1881993749
Name:WOLVERINE ACADEMY, LLC
Entity type:Organization
Organization Name:WOLVERINE ACADEMY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DESIGNEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BARRETT-GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-746-3442
Mailing Address - Street 1:15700 E CLARK RD
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15700 E CLARK RD
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8705
Practice Address - Country:US
Practice Address - Phone:907-746-3442
Practice Address - Fax:907-746-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK942851320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities