Provider Demographics
NPI:1598117848
Name:FULL BLOSSOM BEHAVIORAL HEALTH CONSULTANTS, LLC
Entity Type:Organization
Organization Name:FULL BLOSSOM BEHAVIORAL HEALTH CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BRIGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LCSW
Authorized Official - Phone:888-310-8388
Mailing Address - Street 1:125 TOWNPARK DR NW
Mailing Address - Street 2:300
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5803
Mailing Address - Country:US
Mailing Address - Phone:888-310-8388
Mailing Address - Fax:888-310-8388
Practice Address - Street 1:125 TOWNPARK DR NW
Practice Address - Street 2:300
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5803
Practice Address - Country:US
Practice Address - Phone:888-310-8388
Practice Address - Fax:888-310-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0049251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1780009217OtherNPPES