Provider Demographics
NPI:1972650414
Name:ROCKWELL DEVELOPMENT CENTER, INC. - STICKNEY HOUSE
Entity Type:Organization
Organization Name:ROCKWELL DEVELOPMENT CENTER, INC. - STICKNEY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:OKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MS, QP
Authorized Official - Phone:704-987-2096
Mailing Address - Street 1:120 ROCKWELL LOOP
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-9741
Mailing Address - Country:US
Mailing Address - Phone:704-987-2096
Mailing Address - Fax:704-987-2096
Practice Address - Street 1:120 ROCKWELL LOOP
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-9741
Practice Address - Country:US
Practice Address - Phone:704-987-2096
Practice Address - Fax:704-987-2096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-049-098320800000X, 322D00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603887Medicaid