Provider Demographics
NPI:1629125109
Name:ST. MARK'S MANOR INC
Entity Type:Organization
Organization Name:ST. MARK'S MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-363-5311
Mailing Address - Street 1:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-1057
Mailing Address - Country:US
Mailing Address - Phone:919-363-5311
Mailing Address - Fax:
Practice Address - Street 1:3733 HERITAGE MEADOW LANE
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540
Practice Address - Country:US
Practice Address - Phone:919-363-5311
Practice Address - Fax:919-363-5312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty