Provider Demographics
NPI:1467670752
Name:SANCTUARY HOUSE
Entity Type:Organization
Organization Name:SANCTUARY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE AND CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-275-7896
Mailing Address - Street 1:PO BOX 21141
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27420-1141
Mailing Address - Country:US
Mailing Address - Phone:336-275-7896
Mailing Address - Fax:
Practice Address - Street 1:518 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2018
Practice Address - Country:US
Practice Address - Phone:336-275-7896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-0410632251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300937GMedicaid
NC8300937SMedicaid