Provider Demographics
NPI:1477111334
Name:THE FERN CENTER FOR LIFE
Entity Type:Organization
Organization Name:THE FERN CENTER FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-694-4205
Mailing Address - Street 1:1624 NEWTON AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2116
Mailing Address - Country:US
Mailing Address - Phone:404-694-4205
Mailing Address - Fax:877-759-8014
Practice Address - Street 1:158 MORELAND AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1676
Practice Address - Country:US
Practice Address - Phone:404-694-4205
Practice Address - Fax:877-759-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003766OtherLICENSE