=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629125109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. MARK'S MANOR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3733 HERITAGE MEADOW LANE
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-363-5311
-----------------------------------------------------
Fax | 919-363-5312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1057
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27540-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-363-5311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. PRISCILLA C PETTY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-363-5311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MHL-092-399
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------