Provider Demographics
NPI:1487882254
Name:SPIRIT LODGE
Entity type:Organization
Organization Name:SPIRIT LODGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORP. DIRECTOR OF OUTCOMES IMPROVEM
Authorized Official - Prefix:
Authorized Official - First Name:LEANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GADBOIS-SILLS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:713-933-1391
Mailing Address - Street 1:840 COUNTY ROAD 420
Mailing Address - Street 2:
Mailing Address - City:SPICEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78669-3077
Mailing Address - Country:US
Mailing Address - Phone:830-798-2220
Mailing Address - Fax:830-798-2225
Practice Address - Street 1:840 COUNTY ROAD 420
Practice Address - Street 2:
Practice Address - City:SPICEWOOD
Practice Address - State:TX
Practice Address - Zip Code:78669-3077
Practice Address - Country:US
Practice Address - Phone:830-798-2220
Practice Address - Fax:830-798-2225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRS BEHAVIORAL CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX562-3063324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility