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SITE ENROLLMENT FOR SPECIFIC SERVICES
Complete this form for every site, including the main site that will provide services. Copy as needed.
Provider Name:
Tax ID :_____________________________________
Site Name:
Is this the main site : yes or no
Addresses for this Site
Physical address:
Street
City
State
ZIP Code+4
Street
City
State
ZIP Code+4
Street
City
State
ZIP Code+4
Mailing address:
Billing address:
Information about the Facility/Site Director/Supervisor:
Site Contact Name:
Site Contact’s Title:
Site Contact E-mail Address:
Site Contact Phone Number:
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Complete the following table to show the services to be delivered to Alliance consumers at this
site. The Medicaid ID (MPN), Taxonomy and NPI are to be listed next to each service. If the
license number is not blocked (gray highlighted), write the license number and include a copy of
the facility license.
Services Provided at this Site
Service
Currently
Delivered
for Alliance
Consumers
Taxonomy
in NC
tracks
Medicaid
ID (MPN)
NPI
License
Number
Outpatient
Outpatient – additional ID
Outpatient additional ID
Ambulatory detoxification
Assertive Community Treatment Team
ACTT
Child and Adolescent Day Treatment
(MH/SA)
Community Support Team – CST
(MH/SA)
Diagnostic Assessment (MH/DD/SA)
Inpatient Hospital Psychiatric
Treatment (MH)
Inpatient Hospital Substance Abuse
Treatment
Intensive In-Home Services
Medically Supervised or ADATC
Detoxification/Crisis Stabilization
Mobile Crisis Management (MH/SA/DD)
Multi-Systemic Therapy - MST
Non-Hospital Medical Detoxification
Psychiatric Residential Treatment
Facility – PRTF
Psychosocial Rehabilitation - PSR
Social Setting Detoxification
Substance Abuse Comprehensive
Outpatient Treatment Program - SACOT
Substance Abuse Halfway House
Substance Abuse Intensive Outpatient
Program – SAIOP
Substance Abuse Medically Monitored
Community Residential Treatment
Program
Substance Abuse Non-Medical
Community Residential Treatment
Program
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Service
Currently
Delivered
for Alliance
Consumers
Taxonomy
in NC
tracks
Medicaid
ID (MPN)
NPI
License
Number
Facility Based Crisis Program
Opioid Treatment
Community Guide Services
Community Networking Services
Community Transition Services
Primary Crisis Services
Day Supports
Day Supports – Developmental Day
Financial Support Services
In-Home Skill Building
Personal Care
In-Home Intensive Support
Natural Supports Education
Respite
Out of Home Crisis
Specialized Consultation Services
Supported Employment
Residential Supports Level I
Residential Supports Level I – AFL
Residential Supports Level II
Residential Supports Level II – AFL
Residential Supports Level III
Residential Supports Level III – AFL
Residential Supports Level IV
Residential Supports Level IV – AFL
Level II Residential Services (Program
Type)
Level II Residential Services (Family
Type)
Level III Residential Services
Level IV Residential Services
Intermediate Care Facility
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