Provider Demographics
NPI:1669689766
Name:PICKETT GROVE SUPERVISED LIVING
Entity type:Organization
Organization Name:PICKETT GROVE SUPERVISED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CEDRIKA
Authorized Official - Middle Name:YARNELL
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-403-9644
Mailing Address - Street 1:3809 PICKETT RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5331
Mailing Address - Country:US
Mailing Address - Phone:919-403-9644
Mailing Address - Fax:919-489-8489
Practice Address - Street 1:3809 PICKETT RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-5331
Practice Address - Country:US
Practice Address - Phone:919-403-9644
Practice Address - Fax:919-489-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 032244320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities