Provider Demographics
NPI:1629492053
Name:GEORGIA CENTER FOR MENTAL WELLNESS, LLC
Entity Type:Organization
Organization Name:GEORGIA CENTER FOR MENTAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARA
Authorized Official - Middle Name:BECKETT
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:678-438-9084
Mailing Address - Street 1:563 IVEY WAY SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-4563
Mailing Address - Country:US
Mailing Address - Phone:678-438-9084
Mailing Address - Fax:770-825-9120
Practice Address - Street 1:3050 ATLANTA RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8255
Practice Address - Country:US
Practice Address - Phone:678-438-9084
Practice Address - Fax:770-825-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0043771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122272BMedicaid