Provider Demographics
NPI:1912125295
Name:THERESEA OPEN ARMS
Entity Type:Organization
Organization Name:THERESEA OPEN ARMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MR
Authorized Official - First Name:THERESEA
Authorized Official - Middle Name:MARCELLA
Authorized Official - Last Name:GANAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-882-6325
Mailing Address - Street 1:1277 SIECKMANN LN
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2216
Mailing Address - Country:US
Mailing Address - Phone:660-882-6325
Mailing Address - Fax:
Practice Address - Street 1:1277 SIECKMANN LN
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2216
Practice Address - Country:US
Practice Address - Phone:660-882-6325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities