Provider Demographics
NPI:1003358839
Name:HIGHLAND RIVERS CSB
Entity Type:Organization
Organization Name:HIGHLAND RIVERS CSB
Other - Org Name:GORDON HOME AGAIN
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CEO
Authorized Official - Phone:706-270-5000
Mailing Address - Street 1:1401 APPLEWOOD DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2699
Mailing Address - Country:US
Mailing Address - Phone:706-270-5000
Mailing Address - Fax:706-370-7749
Practice Address - Street 1:419 N WALL ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-1943
Practice Address - Country:US
Practice Address - Phone:706-270-5000
Practice Address - Fax:706-370-7749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHLAND RIVERS COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2111Medicare PIN