Provider Demographics
NPI:1629237508
Name:CG&D ADDICTION SERVICES OF GEORGIA, INC.
Entity Type:Organization
Organization Name:CG&D ADDICTION SERVICES OF GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:CASAC
Authorized Official - Phone:631-691-0769
Mailing Address - Street 1:4540 MEMORIAL DR BLDG D
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1499
Mailing Address - Country:US
Mailing Address - Phone:404-292-8175
Mailing Address - Fax:404-292-8180
Practice Address - Street 1:4540 MEMORIAL DR BLDG D
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1499
Practice Address - Country:US
Practice Address - Phone:404-292-8175
Practice Address - Fax:404-292-8180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-673-D251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health