Provider Demographics
NPI:1558371492
Name:DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Other - Org Name:ADOLESCENT TRANSITIONAL LIVING PROGRAM (GIRLS)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SERVICE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-568-5118
Mailing Address - Street 1:4916 LAPALOMA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-2741
Mailing Address - Country:US
Mailing Address - Phone:706-221-7190
Mailing Address - Fax:
Practice Address - Street 1:4916 LAPALOMA DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-2741
Practice Address - Country:US
Practice Address - Phone:706-221-7190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA - PER CALL TO NPI261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000870768DMedicaid