Provider Demographics
NPI:1710144738
Name:PELHAM SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:PELHAM SUPPORTIVE SERVICES
Other - Org Name:PELHAM GROUP HOME #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-630-6757
Mailing Address - Street 1:949 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-2907
Mailing Address - Country:US
Mailing Address - Phone:910-630-6757
Mailing Address - Fax:
Practice Address - Street 1:4906 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4213
Practice Address - Country:US
Practice Address - Phone:910-826-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-824320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness