Provider Demographics
NPI:1497407506
Name:BLACK SHEEP TRAUMA AND RECOVERY LLC
Entity Type:Organization
Organization Name:BLACK SHEEP TRAUMA AND RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDENER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMFT
Authorized Official - Phone:678-577-8795
Mailing Address - Street 1:125 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5142
Mailing Address - Country:US
Mailing Address - Phone:678-577-8795
Mailing Address - Fax:
Practice Address - Street 1:125 E MONROE ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5142
Practice Address - Country:US
Practice Address - Phone:404-860-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003226805AMedicaid