Provider Demographics
NPI:1396370862
Name:PURE HEART BEHAVIORAL THERAPY, LLC
Entity Type:Organization
Organization Name:PURE HEART BEHAVIORAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELDON
Authorized Official - Suffix:
Authorized Official - Credentials:MAT, BCBA
Authorized Official - Phone:478-569-6235
Mailing Address - Street 1:PO BOX 702
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059
Mailing Address - Country:US
Mailing Address - Phone:478-569-6235
Mailing Address - Fax:478-238-8920
Practice Address - Street 1:359 SHADY DALE RD
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024
Practice Address - Country:US
Practice Address - Phone:478-569-6235
Practice Address - Fax:478-238-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-05
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health