Provider Demographics
NPI:1437838612
Name:GREEN ACRES BAPTIST CHURCH
Entity Type:Organization
Organization Name:GREEN ACRES BAPTIST CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-A
Authorized Official - Phone:903-533-1817
Mailing Address - Street 1:1607 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5799
Mailing Address - Country:US
Mailing Address - Phone:903-533-1817
Mailing Address - Fax:
Practice Address - Street 1:5755 EAGLES NEST BLVD STE 4
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6236
Practice Address - Country:US
Practice Address - Phone:903-533-1817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-14
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty