Provider Demographics
NPI:1265838544
Name:CROSSROADS CHURCH OF DOUGLASVILLE
Entity Type:Organization
Organization Name:CROSSROADS CHURCH OF DOUGLASVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COUNSELING
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-996-0170
Mailing Address - Street 1:5960 STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2372
Mailing Address - Country:US
Mailing Address - Phone:404-996-0170
Mailing Address - Fax:
Practice Address - Street 1:5960 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2372
Practice Address - Country:US
Practice Address - Phone:404-996-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003962101YP2500X
GACSW0053161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty