Provider Demographics
NPI:1508208836
Name:GEORGIA INTEGRATED BEHAVIORAL HEALTHCARE
Entity Type:Organization
Organization Name:GEORGIA INTEGRATED BEHAVIORAL HEALTHCARE
Other - Org Name:GEORGIA INTEGRATED HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULAI
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:678-477-3476
Mailing Address - Street 1:1075 ZONOLITE RD NE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-2013
Mailing Address - Country:US
Mailing Address - Phone:678-477-3476
Mailing Address - Fax:770-991-4803
Practice Address - Street 1:525 MICA TRCE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-8479
Practice Address - Country:US
Practice Address - Phone:678-477-3476
Practice Address - Fax:770-991-4803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health