Provider Demographics
NPI:1598827594
Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Other - Org Name:MASSEYVILLE RD
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-752-3231
Mailing Address - Street 1:2275 GRAY HWY
Mailing Address - Street 2:APT. C-2
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1069
Mailing Address - Country:US
Mailing Address - Phone:478-751-4519
Mailing Address - Fax:
Practice Address - Street 1:2275 GRAY HWY
Practice Address - Street 2:APT. C-2
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1069
Practice Address - Country:US
Practice Address - Phone:478-751-4519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2149Medicare ID - Type Unspecified