Provider Demographics
NPI:1356646160
Name:BEHAVIORAL HEALTH OF MIDDLE GEORGIA, LLC
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH OF MIDDLE GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DNETRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-328-2806
Mailing Address - Street 1:22 FOREST CIR
Mailing Address - Street 2:#502
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1112
Mailing Address - Country:US
Mailing Address - Phone:770-328-2806
Mailing Address - Fax:
Practice Address - Street 1:1170 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31027-3201
Practice Address - Country:US
Practice Address - Phone:770-328-2806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0527251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health