Provider Demographics
NPI:1114769130
Name:THAT 1 HOME
Entity type:Organization
Organization Name:THAT 1 HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-EGESI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:832-785-4089
Mailing Address - Street 1:19126 MOSSY HEDGE LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-4133
Mailing Address - Country:US
Mailing Address - Phone:832-785-4089
Mailing Address - Fax:
Practice Address - Street 1:19126 MOSSY HEDGE LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-4133
Practice Address - Country:US
Practice Address - Phone:832-785-4089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term CareGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty