Provider Demographics
NPI:1306072780
Name:PROSPECT MOUNTAIN THERAPEUTIC RIDING CENTER
Entity type:Organization
Organization Name:PROSPECT MOUNTAIN THERAPEUTIC RIDING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSTRUCTOR, CEO
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:LISENBY
Authorized Official - Suffix:
Authorized Official - Credentials:INSTRUCTOR RN
Authorized Official - Phone:469-595-2019
Mailing Address - Street 1:7471 FM 3094
Mailing Address - Street 2:
Mailing Address - City:SCURRY
Mailing Address - State:TX
Mailing Address - Zip Code:75158-4915
Mailing Address - Country:US
Mailing Address - Phone:469-595-2019
Mailing Address - Fax:972-452-3331
Practice Address - Street 1:7471 FM 3094
Practice Address - Street 2:
Practice Address - City:SCURRY
Practice Address - State:TX
Practice Address - Zip Code:75158-4915
Practice Address - Country:US
Practice Address - Phone:469-595-2019
Practice Address - Fax:972-452-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty