Provider Demographics
NPI:1154560050
Name:SUSIE'S PLACE
Entity type:Organization
Organization Name:SUSIE'S PLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-380-0772
Mailing Address - Street 1:PO BOX 5144
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-5144
Mailing Address - Country:US
Mailing Address - Phone:336-380-0772
Mailing Address - Fax:336-270-6303
Practice Address - Street 1:724 ASKEW ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-2202
Practice Address - Country:US
Practice Address - Phone:336-380-0772
Practice Address - Fax:336-270-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3747P1801X322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children