Provider Demographics
NPI:1235674375
Name:WBC GEORGIA LLC
Entity Type:Organization
Organization Name:WBC GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:781-647-6767
Mailing Address - Street 1:51 SAWYER RD
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4536 BARCLAY DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7145
Practice Address - Country:US
Practice Address - Phone:770-458-8711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility