Provider Demographics
NPI:1538363486
Name:LACLEDE ASSOCIATION FOR DEVELOPMENTAL DISABILITIES
Entity type:Organization
Organization Name:LACLEDE ASSOCIATION FOR DEVELOPMENTAL DISABILITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-588-1577
Mailing Address - Street 1:200 LAWSON AVE.
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536
Mailing Address - Country:US
Mailing Address - Phone:417-588-1577
Mailing Address - Fax:
Practice Address - Street 1:200 LAWSON AVE.
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536
Practice Address - Country:US
Practice Address - Phone:417-588-1577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385H00000X
MO605385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639201080Medicaid