Basic Information
Provider Information | |||||||||
NPI: | 1841315132 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PITT COUNTY GROUP HOME BOARD FOR MENTALLY RETARDED, AUTISTIC PERSONS, | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9 | ||||||||
Address2: |   | ||||||||
City: | GRIFTON | ||||||||
State: | NC | ||||||||
PostalCode: | 285300009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2525244950 | ||||||||
FaxNumber: | 2525243870 | ||||||||
Practice Location | |||||||||
Address1: | 560 WEST QUEEN ST. | ||||||||
Address2: |   | ||||||||
City: | GRIFTON | ||||||||
State: | NC | ||||||||
PostalCode: | 285300009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2525244950 | ||||||||
FaxNumber: | 2525243870 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRIGHT | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | GRACE | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2525244950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | MHL074003 | NC | N |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   | 320600000X | MHL074015 | NC | N |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   | 320600000X | MHL074097 | NC | N |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   | 320600000X | MHL074037 | NC | N |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   | 320600000X | MHL074021 | NC | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   |
ID Information
ID | Type | State | Issuer | Description | 7802576 | 05 | NC |   | MEDICAID | 7802610 | 05 | NC |   | MEDICAID | 3406304 | 05 | NC |   | MEDICAID | 3406541 | 05 | NC |   | MEDICAID |