Provider Demographics
NPI:1649348483
Name:LUCILLE'S BEHAVIORAL, INC.
Entity type:Organization
Organization Name:LUCILLE'S BEHAVIORAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:SAULS
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-747-1001
Mailing Address - Street 1:204 HWY 58 N
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-8402
Mailing Address - Country:US
Mailing Address - Phone:252-574-7100
Mailing Address - Fax:252-747-1001
Practice Address - Street 1:204 HWY 58 N
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-8402
Practice Address - Country:US
Practice Address - Phone:252-574-7100
Practice Address - Fax:252-747-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL040018320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805142Medicaid
NC3409488Medicaid
NC8300985Medicaid