Provider Demographics
NPI:1609980556
Name:BRUSHY MOUNTAIN GROUP HOMES, INC.
Entity Type:Organization
Organization Name:BRUSHY MOUNTAIN GROUP HOMES, INC.
Other - Org Name:MULBERRY GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-838-3789
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-1045
Mailing Address - Country:US
Mailing Address - Phone:336-838-3789
Mailing Address - Fax:336-838-3490
Practice Address - Street 1:1904 WINDY RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-8752
Practice Address - Country:US
Practice Address - Phone:336-670-2265
Practice Address - Fax:336-838-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL097044320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804484Medicaid