Healthcare Provider Details

I. General information

NPI: 1609790435
Provider Name (Legal Business Name): GLORY GROUP HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ONYX CT
DURHAM NC
27703-2680
US

IV. Provider business mailing address

5 ONYX CT
DURHAM NC
27703-2680
US

V. Phone/Fax

Practice location:
  • Phone: 919-408-4945
  • Fax: 984-377-8660
Mailing address:
  • Phone: 919-408-4945
  • Fax: 984-377-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JASMINE SHAVON BETHEA
Title or Position: OWNER
Credential: MSW,LCSW,LCAS
Phone: 919-408-4945