Provider Demographics
NPI:1336480201
Name:PROVIDENCE RESIDENTIAL & OUTPATIENT PTSD SERVICES (PROPS)
Entity Type:Organization
Organization Name:PROVIDENCE RESIDENTIAL & OUTPATIENT PTSD SERVICES (PROPS)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY-MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-882-5371
Mailing Address - Street 1:PO BOX 5464
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154-0008
Mailing Address - Country:US
Mailing Address - Phone:678-882-5371
Mailing Address - Fax:
Practice Address - Street 1:3400 CHAPEL HILL RD
Practice Address - Street 2:SUITE 100 PMB #08
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1739
Practice Address - Country:US
Practice Address - Phone:678-882-5371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness