Provider Demographics
NPI:1114706132
Name:RADIANCE BEHAVIOR THERAPY, LLC
Entity Type:Organization
Organization Name:RADIANCE BEHAVIOR THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LADRONDEGUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-480-8790
Mailing Address - Street 1:3901 MARY ELIZA TRCE NW STE 202
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1096
Mailing Address - Country:US
Mailing Address - Phone:470-615-6277
Mailing Address - Fax:
Practice Address - Street 1:3901 MARY ELIZA TRCE NW STE 202
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1096
Practice Address - Country:US
Practice Address - Phone:470-615-6277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-28
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty