Healthcare Provider Details

I. General information

NPI: 1598782377
Provider Name (Legal Business Name): FAMILY HOME LIFE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 JULIAN R ALLSBROOK HWY
ROANOKE RAPIDS NC
27870-4611
US

IV. Provider business mailing address

PO BOX 66
ROANOKE RAPIDS NC
27870-0066
US

V. Phone/Fax

Practice location:
  • Phone: 252-533-9200
  • Fax:
Mailing address:
  • Phone: 252-533-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL042038
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberMHL042038
License Number StateNC

VIII. Authorized Official

Name: DEBORAH GRAY TANNER
Title or Position: DIRECTOR OWNER
Credential:
Phone: 252-533-9200