Provider Demographics
NPI:1982844635
Name:PROFESSIONAL GROUP LIVING,LLC
Entity Type:Organization
Organization Name:PROFESSIONAL GROUP LIVING,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LLEWELLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:910-592-2338
Mailing Address - Street 1:715 SOUTHWEST BLVD
Mailing Address - Street 2:B
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-4636
Mailing Address - Country:US
Mailing Address - Phone:919-592-2338
Mailing Address - Fax:910-592-5508
Practice Address - Street 1:4084 BARRETT DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6604
Practice Address - Country:US
Practice Address - Phone:919-785-9660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL082075251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services