Provider Demographics
NPI:1619424231
Name:DEVEREUX GOERGIA TREATMENT NETWORK
Entity Type:Organization
Organization Name:DEVEREUX GOERGIA TREATMENT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-427-0147
Mailing Address - Street 1:1291 STANLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4359
Mailing Address - Country:US
Mailing Address - Phone:770-427-0147
Mailing Address - Fax:
Practice Address - Street 1:1291 STANLEY RD
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152
Practice Address - Country:US
Practice Address - Phone:770-427-0147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0038001323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility