1619091519 NPI number — CHRISTIAN COUNSELING AND PSYCHOLOGICAL SERVICES, INC

Table of content: (NPI 1619091519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619091519 NPI number — CHRISTIAN COUNSELING AND PSYCHOLOGICAL SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTIAN COUNSELING AND PSYCHOLOGICAL SERVICES, INC
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:
ATLANTA FORENSIC & MENTAL HEALTH INSTITUTE
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:
1619091519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2910 HORIZON PARK DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-7256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-271-8989
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2910 HORIZON PARK DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-7256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-271-8989
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REASONER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHOLOGIST PRESIDENT
Authorized Official Telephone Number:
770-271-8989

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  1438 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00479938A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".