Provider Demographics
NPI:1790829158
Name:BJ PROFESSIONAL SERVICES, INC.
Entity Type:Organization
Organization Name:BJ PROFESSIONAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TWYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEREEN
Authorized Official - Suffix:
Authorized Official - Credentials:QP
Authorized Official - Phone:910-862-2484
Mailing Address - Street 1:1206 TWISTED HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-5216
Mailing Address - Country:US
Mailing Address - Phone:910-862-2484
Mailing Address - Fax:910-862-6121
Practice Address - Street 1:1206 TWISTED HICKORY RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-5216
Practice Address - Country:US
Practice Address - Phone:910-862-2484
Practice Address - Fax:910-862-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-078-109320900000X
NCMHL-009-025320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408787Medicaid