Provider Demographics
NPI:1902999568
Name:PENTECOSTAL TEMPLE RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:PENTECOSTAL TEMPLE RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QP
Authorized Official - Phone:252-752-6951
Mailing Address - Street 1:PO BOX 983
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-0983
Mailing Address - Country:US
Mailing Address - Phone:252-752-0057
Mailing Address - Fax:252-830-4094
Practice Address - Street 1:2753 W 5TH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7817
Practice Address - Country:US
Practice Address - Phone:252-752-0057
Practice Address - Fax:252-830-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-115322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children