Basic Information
| Provider Information | |||||||||
| NPI: | 1093828881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC.-HOPE MEADOW PROGRAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY WELLNESS AND RECOVERY SERVICES OF NC, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E WEAVER ST | ||||||||
| Address2: | STE. G-7 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275102370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199330770 | ||||||||
| FaxNumber: | 9199330767 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 PENNY LN | ||||||||
| Address2: | |||||||||
| City: | PITTSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273124918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199688680 | ||||||||
| FaxNumber: | 9199689970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUTTER | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | THERESE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9199330770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | MHL-019017 | NC | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 6110548 | 05 | NC | MEDICAID | 8300816B | 05 | NC | MEDICAID | 8300816G | 05 | NC | MEDICAID | 8302193P | 05 | NC | MEDICAID | 8300816 | 05 | NC | MEDICAID | 8300816P | 05 | NC | MEDICAID | 8302193G | 05 | NC | MEDICAID | 6005680 | 05 | NC | MEDICAID | 6106030 | 05 | NC | MEDICAID | 8302193 | 05 | NC | MEDICAID | 6000789 | 05 | NC | MEDICAID | 6103305 | 05 | NC | MEDICAID | 8302193B | 05 | NC | MEDICAID |