Provider Demographics
NPI:1609916147
Name:FAMILY ART THERAPY CENTER PC
Entity Type:Organization
Organization Name:FAMILY ART THERAPY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, ATR-BC
Authorized Official - Phone:064-903-5357
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0043
Mailing Address - Country:US
Mailing Address - Phone:706-782-0717
Mailing Address - Fax:706-782-5266
Practice Address - Street 1:109 OLD LIVERY STREET
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-782-0717
Practice Address - Fax:706-782-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC 003219101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10045514OtherCMO AMERIGROUP
GA743776000OtherCMO MAGELLAN
GA052483465AMedicaid