Provider Demographics
NPI:1528188802
Name:MURRAY ADOLESCENT TRAINING & TXMENT ACADEMY
Entity Type:Organization
Organization Name:MURRAY ADOLESCENT TRAINING & TXMENT ACADEMY
Other - Org Name:PROMISE KEEPERS GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-372-4915
Mailing Address - Street 1:2012 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5022
Mailing Address - Country:US
Mailing Address - Phone:704-372-4915
Mailing Address - Fax:704-372-4917
Practice Address - Street 1:2012 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5022
Practice Address - Country:US
Practice Address - Phone:704-372-4915
Practice Address - Fax:704-372-4917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC060-394322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603431Medicaid