Provider Demographics
NPI:1912167511
Name:GLADY'S GROUP HOME INC
Entity Type:Organization
Organization Name:GLADY'S GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:YAMARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-343-8472
Mailing Address - Street 1:213 SW LANGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4926
Mailing Address - Country:US
Mailing Address - Phone:772-343-8472
Mailing Address - Fax:772-879-6737
Practice Address - Street 1:213 SW LANGFIELD AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-4926
Practice Address - Country:US
Practice Address - Phone:772-343-8472
Practice Address - Fax:772-879-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689362796320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities