Provider Demographics
NPI:1174667901
Name:THE EPIPHANY CENTER
Entity Type:Organization
Organization Name:THE EPIPHANY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:770-760-8763
Mailing Address - Street 1:1791 WALKER RD SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3126
Mailing Address - Country:US
Mailing Address - Phone:770-760-8763
Mailing Address - Fax:770-760-8765
Practice Address - Street 1:1791 WALKER RD SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3126
Practice Address - Country:US
Practice Address - Phone:770-760-8763
Practice Address - Fax:770-760-8765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health