Provider Demographics
NPI:1144605650
Name:POINCIANA RECOVERY INSTITUTE
Entity Type:Organization
Organization Name:POINCIANA RECOVERY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-966-3557
Mailing Address - Street 1:1301 SHILOH RD NW
Mailing Address - Street 2:SUITE 1531B
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7147
Mailing Address - Country:US
Mailing Address - Phone:404-966-3557
Mailing Address - Fax:
Practice Address - Street 1:1301 SHILOH RD NW
Practice Address - Street 2:SUITE 1531B
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7147
Practice Address - Country:US
Practice Address - Phone:404-966-3557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-26
Last Update Date:2015-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health