Provider Demographics
NPI:1487702619
Name:PROFESSIONAL GROUP LIVING
Entity type:Organization
Organization Name:PROFESSIONAL GROUP LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATALKA
Authorized Official - Middle Name:AQUINAIRIA
Authorized Official - Last Name:LOCK MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, PLCSW
Authorized Official - Phone:919-264-1440
Mailing Address - Street 1:510 SIMMONS ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-4334
Mailing Address - Country:US
Mailing Address - Phone:919-688-0818
Mailing Address - Fax:010-688-0918
Practice Address - Street 1:510 SIMMONS ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-4334
Practice Address - Country:US
Practice Address - Phone:919-688-0818
Practice Address - Fax:010-688-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301532Medicaid