Provider Demographics
NPI:1609581800
Name:CLASSROOM21
Entity Type:Organization
Organization Name:CLASSROOM21
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:O'BARA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:912-281-2251
Mailing Address - Street 1:527 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-2700
Mailing Address - Country:US
Mailing Address - Phone:478-396-5489
Mailing Address - Fax:
Practice Address - Street 1:527 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-2700
Practice Address - Country:US
Practice Address - Phone:478-396-5489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty