Provider Demographics
NPI:1033694906
Name:WOODRIDGE OF WEST MEMPHIS, LLC
Entity Type:Organization
Organization Name:WOODRIDGE OF WEST MEMPHIS, LLC
Other - Org Name:WOODRIDGE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. OF ADMIN. SVCS
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-554-7903
Mailing Address - Street 1:2520 NORTHWINDS PKWY STE 550
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2236
Mailing Address - Country:US
Mailing Address - Phone:470-554-7903
Mailing Address - Fax:
Practice Address - Street 1:800 S CHURCH ST STE 103
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4154
Practice Address - Country:US
Practice Address - Phone:470-554-7903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REP PERIMETER HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-26
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health