Provider Demographics
NPI:1215395454
Name:FEBLES, GLENNYS SORAYA (ICADC-II)
Entity Type:Individual
Prefix:
First Name:GLENNYS
Middle Name:SORAYA
Last Name:FEBLES
Suffix:
Gender:F
Credentials:ICADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 FOLSOM RD SE
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:GA
Mailing Address - Zip Code:30139-2614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 SHUGART RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2467
Practice Address - Country:US
Practice Address - Phone:800-715-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84567101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)