Provider Demographics
NPI:1710056742
Name:BELLFLOWER LANE
Entity Type:Organization
Organization Name:BELLFLOWER LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR BUSINESS DEVELOPMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:BA QP QSAPP
Authorized Official - Phone:704-566-6134
Mailing Address - Street 1:PO BOX 480794
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5323
Mailing Address - Country:US
Mailing Address - Phone:704-566-6134
Mailing Address - Fax:704-566-6136
Practice Address - Street 1:3124 MILTON RD
Practice Address - Street 2:SUITE 231
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5008
Practice Address - Country:US
Practice Address - Phone:704-566-6134
Practice Address - Fax:704-566-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-575322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603949Medicaid