Provider Demographics
NPI:1063569127
Name:BERTHA'S PLACE, INC.
Entity type:Organization
Organization Name:BERTHA'S PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-598-5106
Mailing Address - Street 1:2424 LOGAN FIELD DR.
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6962
Mailing Address - Country:US
Mailing Address - Phone:704-243-4771
Mailing Address - Fax:704-243-4771
Practice Address - Street 1:3412 GREEN MEADOW DR.
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-2982
Practice Address - Country:US
Practice Address - Phone:704-598-5106
Practice Address - Fax:704-598-5106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL060-871322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603939Medicaid