1841486305 NPI number — GEORGIA YOUTH NETWORK INC

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 1841486305 NPI number — GEORGIA YOUTH NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA YOUTH NETWORK 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:
GEORGIA FAMILY THERAPY SERVICES INC
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:
1841486305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 82322
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30013-9434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-344-8704
Provider Business Mailing Address Fax Number:
770-216-1723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30083-3098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-344-8704
Provider Business Practice Location Address Fax Number:
770-216-1723
Provider Enumeration Date:
09/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PORTER
Authorized Official First Name:
JANINE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
770-344-8704

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  NONE , 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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