Provider Demographics
NPI:1487701868
Name:POTTERHOUSE SANCTUARY LIBERATION
Entity type:Organization
Organization Name:POTTERHOUSE SANCTUARY LIBERATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-223-4511
Mailing Address - Street 1:7344 BERKSHIRE DOWNS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5636
Mailing Address - Country:US
Mailing Address - Phone:919-217-9119
Mailing Address - Fax:919-217-9118
Practice Address - Street 1:2805 AUBURN KNIGHTDALE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-9712
Practice Address - Country:US
Practice Address - Phone:919-217-9119
Practice Address - Fax:919-217-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL029640320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities