Provider Demographics
NPI:1710160759
Name:SIERRA'S RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:SIERRA'S RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTTIE
Authorized Official - Middle Name:JEFFERY
Authorized Official - Last Name:VANHOOK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-257-1156
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-0655
Mailing Address - Country:US
Mailing Address - Phone:910-257-1156
Mailing Address - Fax:
Practice Address - Street 1:21 LANEXA RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-8274
Practice Address - Country:US
Practice Address - Phone:910-497-4096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIERRA'S RESIDENTIAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-043-039322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603401Medicaid