Provider Demographics
NPI:1487191714
Name:BLOUNT YOUTH HOME OF GEORGIA, INC
Entity Type:Organization
Organization Name:BLOUNT YOUTH HOME OF GEORGIA, INC
Other - Org Name:CAMPSIDE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:770-550-1084
Mailing Address - Street 1:582 MEL BLOUNT RD
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-9714
Mailing Address - Country:US
Mailing Address - Phone:770-550-1084
Mailing Address - Fax:
Practice Address - Street 1:582 MEL BLOUNT RD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-9714
Practice Address - Country:US
Practice Address - Phone:770-550-1084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health