Provider Demographics
NPI:1639205701
Name:GILL HOUSE
Entity Type:Organization
Organization Name:GILL HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARDRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-828-5339
Mailing Address - Street 1:1412 GRIFFIN CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4928
Mailing Address - Country:US
Mailing Address - Phone:919-828-5339
Mailing Address - Fax:919-755-0355
Practice Address - Street 1:845 CROSS LINK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-4730
Practice Address - Country:US
Practice Address - Phone:919-755-0791
Practice Address - Fax:919-755-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL092590322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603754Medicaid