Provider Demographics
NPI:1528242484
Name:HARBOR HOUSE # V
Entity type:Organization
Organization Name:HARBOR HOUSE # V
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-581-3592
Mailing Address - Street 1:2822 CASHWELL DR # 178
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4302
Mailing Address - Country:US
Mailing Address - Phone:919-581-3592
Mailing Address - Fax:919-734-8310
Practice Address - Street 1:1205 S BEST ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-6703
Practice Address - Country:US
Practice Address - Phone:919-581-3592
Practice Address - Fax:919-734-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805805Medicaid
NCMHL096180OtherMENTAL HEALTH LICENCURE