Provider Demographics
NPI:1114273315
Name:FRESH START COMMUNITY DEVELOPERS, LLC
Entity Type:Organization
Organization Name:FRESH START COMMUNITY DEVELOPERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ADDICTION COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CADC, ICRC, SAM
Authorized Official - Phone:404-245-9265
Mailing Address - Street 1:46 SYCAMORE STA
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2757
Mailing Address - Country:US
Mailing Address - Phone:404-245-9265
Mailing Address - Fax:404-370-1202
Practice Address - Street 1:46 SYCAMORE STA
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2757
Practice Address - Country:US
Practice Address - Phone:404-245-9265
Practice Address - Fax:404-370-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA236101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty