Provider Demographics
NPI:1316230899
Name:CORD OF THREE COUNSELING SERVICES, INC.
Entity Type:Organization
Organization Name:CORD OF THREE COUNSELING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:912-282-0992
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:GA
Mailing Address - Zip Code:31557-0151
Mailing Address - Country:US
Mailing Address - Phone:912-282-0992
Mailing Address - Fax:912-647-0510
Practice Address - Street 1:5920 REESE ST
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:GA
Practice Address - Zip Code:31557-5131
Practice Address - Country:US
Practice Address - Phone:912-282-0992
Practice Address - Fax:912-647-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004088251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104129AMedicaid