1700195344 NPI number — EXTRAORDINARY BEHAVIORAL SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700195344 NPI number — EXTRAORDINARY BEHAVIORAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXTRAORDINARY BEHAVIORAL SERVICES
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:
Provider Other Organization Name Type Code:
6
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:
1700195344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 MOUNTAINBROOKE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-2853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-221-8494
Provider Business Mailing Address Fax Number:
832-383-9718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
235 E PONCE DE LEON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-3452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-221-8494
Provider Business Practice Location Address Fax Number:
832-383-9718
Provider Enumeration Date:
09/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TORI
Authorized Official Middle Name:
HATTER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-221-8494

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , 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)





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