Provider Demographics
NPI:1518436179
Name:TRANSFORMATIONS OF STATESBORO LLC
Entity Type:Organization
Organization Name:TRANSFORMATIONS OF STATESBORO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:SELWYN
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:CAC II, CCS
Authorized Official - Phone:912-243-9310
Mailing Address - Street 1:326 MYRTLE CROSSING DR STE 300
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4429
Mailing Address - Country:US
Mailing Address - Phone:912-243-9310
Mailing Address - Fax:912-243-9311
Practice Address - Street 1:326 MYRTLE CROSSING DR STE 300
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4429
Practice Address - Country:US
Practice Address - Phone:912-243-9310
Practice Address - Fax:912-243-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty