Organization
BELLFLOWER LANE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. CLARISSA HENRY BA QP QSAPP (DIRECTOR BUSINESS DEVELOPMENT)
(704) 566-6134
Entity
Organization
Contact information
Practice address
3124 MILTON RD, SUITE 231, CHARLOTTE, NC 28215-5008
(704) 566-6134
(704) 566-6136
Mailing address
PO BOX 480794, CHARLOTTE, NC 28269-5323
(704) 566-6134
(704) 566-6136
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
MHL-060-575
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6603949
—
NC
Enumeration date
11/06/2006
Last updated
08/22/2020
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