Provider Demographics
NPI:1902440209
Name:SUNNYBROOK CHILDREN'S HOME, INC.
Entity Type:Organization
Organization Name:SUNNYBROOK CHILDREN'S HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPANSEL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:601-856-6555
Mailing Address - Street 1:PO BOX 4871
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4871
Mailing Address - Country:US
Mailing Address - Phone:601-856-6555
Mailing Address - Fax:601-856-6520
Practice Address - Street 1:222 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2205
Practice Address - Country:US
Practice Address - Phone:769-972-2934
Practice Address - Fax:601-856-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty