Provider Demographics
NPI:1235314733
Name:WILLIE M. SIMPSON EVANGELISTIC MINISTRIES, INC.
Entity Type:Organization
Organization Name:WILLIE M. SIMPSON EVANGELISTIC MINISTRIES, INC.
Other - Org Name:CROSSROADS YOUTH DEVELOPMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:REV
Authorized Official - Phone:678-249-5323
Mailing Address - Street 1:821 LORRAINE LN
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7624
Mailing Address - Country:US
Mailing Address - Phone:678-249-5323
Mailing Address - Fax:770-507-0304
Practice Address - Street 1:628 SOUTHSIDE COMMERCIAL PKWY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8912
Practice Address - Country:US
Practice Address - Phone:678-249-5323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health