Provider Demographics
NPI:1689749889
Name:GHA AUTISM SUPPORTS
Entity Type:Organization
Organization Name:GHA AUTISM SUPPORTS
Other - Org Name:A. JACK WALL GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:HARWOOD
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-982-9600
Mailing Address - Street 1:PO BOX 2487
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28002-2487
Mailing Address - Country:US
Mailing Address - Phone:704-982-9600
Mailing Address - Fax:704-982-8155
Practice Address - Street 1:1213 MOSS SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-7810
Practice Address - Country:US
Practice Address - Phone:704-982-9600
Practice Address - Fax:704-982-8155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL084017315P00000X, 320600000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406165Medicaid