Provider Demographics
NPI:1194188532
Name:SEEDGROW BEHAVIORAL SERVICES,LLC
Entity Type:Organization
Organization Name:SEEDGROW BEHAVIORAL SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:404-565-6029
Mailing Address - Street 1:505 HEATHERDOWN WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3592
Mailing Address - Country:US
Mailing Address - Phone:678-435-9214
Mailing Address - Fax:
Practice Address - Street 1:505 HEATHERDOWN WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3592
Practice Address - Country:US
Practice Address - Phone:678-435-9214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-02
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01-14-17610251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1497116834OtherNPI
GA13604699OtherCAQH