Healthcare Provider Details

I. General information

NPI: 1467670752
Provider Name (Legal Business Name): SANCTUARY HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 N ELM ST
GREENSBORO NC
27401-2018
US

IV. Provider business mailing address

PO BOX 21141
GREENSBORO NC
27420-1141
US

V. Phone/Fax

Practice location:
  • Phone: 336-275-7896
  • Fax:
Mailing address:
  • Phone: 336-275-7896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-0410632
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH L THEISEN
Title or Position: COMPLIANCE AND CONTRACTS MANAGER
Credential:
Phone: 336-275-7896