Provider Demographics
NPI:1376645796
Name:SOUTHWESTERN STATE HOSPITAL
Entity Type:Organization
Organization Name:SOUTHWESTERN STATE HOSPITAL
Other - Org Name:INTENSIVE TREATMENT RESIDENCE PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HILARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOO-YOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-227-3021
Mailing Address - Street 1:PO BOX 1378
Mailing Address - Street 2:PATIENT BILLING DEPT
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1378
Mailing Address - Country:US
Mailing Address - Phone:229-227-2977
Mailing Address - Fax:229-227-2955
Practice Address - Street 1:307 CLOVERDALE DR
Practice Address - Street 2:INTENSIVE TREATMENT RESIDENCE PROGRAM
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4018
Practice Address - Country:US
Practice Address - Phone:229-227-2977
Practice Address - Fax:229-227-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58-1130678320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA252378193AMedicaid