Provider Demographics
NPI:1003113184
Name:FAMILY 360 INCORPORATED
Entity Type:Organization
Organization Name:FAMILY 360 INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DESMOND
Authorized Official - Middle Name:ORVILLE
Authorized Official - Last Name:MAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-679-0586
Mailing Address - Street 1:2215 EXCHANGE PL SE STE A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6723
Mailing Address - Country:US
Mailing Address - Phone:770-679-0586
Mailing Address - Fax:770-285-6325
Practice Address - Street 1:2215 EXCHANGE PL SE STE A
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6723
Practice Address - Country:US
Practice Address - Phone:770-679-0586
Practice Address - Fax:770-554-9349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT 001191106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty