Organization
GREEN MAXVILLE SUPPORTIVE LIVING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DALE A MAXVILLE JR. PHD, BCBA-D, LBA (PRESIDENT/OWNER)
(573) 864-9743
Entity
Organization
Contact information
Practice address
101 E ALHAMBRA DR, COLUMBIA, MO 65203-3763
(573) 864-9743
(573) 874-1723
Mailing address
5900 GALLI LN, COLLINSVILLE, IL 62234-5836
(573) 864-9743
(573) 874-1713
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
06/22/2015
Last updated
06/22/2015
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