Provider Demographics
NPI:1235454257
Name:GA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:GA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Other - Org Name:GA REGIONAL HOSPITAL AT ATLANTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EMILE
Authorized Official - Middle Name:
Authorized Official - Last Name:RISBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-243-2114
Mailing Address - Street 1:PO BOX 370407
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-0407
Mailing Address - Country:US
Mailing Address - Phone:404-212-5454
Mailing Address - Fax:404-243-2159
Practice Address - Street 1:3073 PANTHERSVILLE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-3828
Practice Address - Country:US
Practice Address - Phone:404-212-5454
Practice Address - Fax:404-243-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-01
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-232283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000141061AMedicaid
GA000141061AMedicaid