Provider Demographics
NPI:1104219096
Name:1HOUSE OF MICAH
Entity type:Organization
Organization Name:1HOUSE OF MICAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:469-478-7106
Mailing Address - Street 1:600 WOODBRIDGE PKWY
Mailing Address - Street 2:UNIT 2133
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-7047
Mailing Address - Country:US
Mailing Address - Phone:469-478-7106
Mailing Address - Fax:
Practice Address - Street 1:600 WOODBRIDGE PKWY
Practice Address - Street 2:UNIT 2133
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-7047
Practice Address - Country:US
Practice Address - Phone:469-478-7106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56214104100000X
251C00000X, 311Z00000X, 320600000X, 320700000X, 320800000X, 320900000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities