Provider Demographics
NPI:1639422603
Name:FAMILY AND CHILD DEVELOPMENT CENTER OF JOHNS CREEK LTD
Entity Type:Organization
Organization Name:FAMILY AND CHILD DEVELOPMENT CENTER OF JOHNS CREEK LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCINDA
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:GRAPENTHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-433-7363
Mailing Address - Street 1:500 ARGYLL CRST
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6118
Mailing Address - Country:US
Mailing Address - Phone:404-433-7363
Mailing Address - Fax:770-645-9281
Practice Address - Street 1:360 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-5467
Practice Address - Country:US
Practice Address - Phone:404-433-7363
Practice Address - Fax:770-645-9281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2289103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000922556AMedicaid