Provider Demographics
NPI:1437657525
Name:BEHAVIORAL HEALTH ASSOICATES OF GEORGIA, LLC
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH ASSOICATES OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FELICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-376-7635
Mailing Address - Street 1:320 LANIER AVE W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1600
Mailing Address - Country:US
Mailing Address - Phone:770-376-7635
Mailing Address - Fax:678-302-0810
Practice Address - Street 1:320 LANIER AVE W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1600
Practice Address - Country:US
Practice Address - Phone:770-376-7635
Practice Address - Fax:678-302-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1477912111OtherINDIVIDUAL NPI