Provider Demographics
NPI:1508381344
Name:THE DAMASCUS ROAD
Entity Type:Organization
Organization Name:THE DAMASCUS ROAD
Other - Org Name:TEAH L. MOORE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/LICENSED PROFESSIONAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TEAH
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:423-943-7754
Mailing Address - Street 1:312 SHANE CIR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-3776
Mailing Address - Country:US
Mailing Address - Phone:423-943-7754
Mailing Address - Fax:
Practice Address - Street 1:733B CARROLL ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3368
Practice Address - Country:US
Practice Address - Phone:423-943-7754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-12
Last Update Date:2017-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0006549251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181539AMedicaid