=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861780322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WICKER STREET GROUP HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2011
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 FLORA AVE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27217-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-227-4350
-----------------------------------------------------
Fax | 336-227-4350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 981
-----------------------------------------------------
City | HAW RIVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27258-0981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-578-0004
-----------------------------------------------------
Fax | 336-227-4350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OWNER
-----------------------------------------------------
Name | MS. DOROTHEA VIVIAN ROGERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-578-0004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | 001-217
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------