1063751014 NPI number — CHANTAY GOLSON

Table of content: DR. CATHERINE JEANHI BAE M.D. (NPI 1700046208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063751014 NPI number — CHANTAY GOLSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANTAY GOLSON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PURPOSE COMMUNITY THERAPEUTIC SERVICES, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063751014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
242 FAIRFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLA RICA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30180-3804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-280-7288
Provider Business Mailing Address Fax Number:
770-983-6098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 BOULEVARD NE
Provider Second Line Business Practice Location Address:
SUITE 611
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30312-1273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-280-7288
Provider Business Practice Location Address Fax Number:
770-983-6098
Provider Enumeration Date:
02/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GOLSON
Authorized Official First Name:
CHANTAY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-280-7288

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003126621A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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