Provider Demographics
NPI:1407952344
Name:LEE COUNTY GROUP HOMES, INC.
Entity Type:Organization
Organization Name:LEE COUNTY GROUP HOMES, INC.
Other - Org Name:LEE # 1 AND LEE # 2
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:QPBS
Authorized Official - Phone:919-776-9189
Mailing Address - Street 1:PO BOX 1373
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-1373
Mailing Address - Country:US
Mailing Address - Phone:919-776-9189
Mailing Address - Fax:919-774-7711
Practice Address - Street 1:3101 CARBONTON RD
Practice Address - Street 2:LEE # 1
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-8214
Practice Address - Country:US
Practice Address - Phone:919-776-9189
Practice Address - Fax:919-774-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 053039320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804513Medicaid
NC295120Medicare ID - Type Unspecified