Provider Demographics
NPI:1053449157
Name:MARTHA'S GROUP HOMES
Entity Type:Organization
Organization Name:MARTHA'S GROUP HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:TREVOUR
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP, BS
Authorized Official - Phone:910-938-0670
Mailing Address - Street 1:516 E SPRINGHILL TER
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7366
Mailing Address - Country:US
Mailing Address - Phone:910-938-0670
Mailing Address - Fax:910-938-1229
Practice Address - Street 1:516 E SPRINGHILL TER
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7366
Practice Address - Country:US
Practice Address - Phone:910-938-0670
Practice Address - Fax:910-938-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL067-069251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301498Medicaid