Provider Demographics
NPI:1689139362
Name:RESILIENCY BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:RESILIENCY BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:POPOV
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-668-3130
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:TURIN
Mailing Address - State:GA
Mailing Address - Zip Code:30289-0302
Mailing Address - Country:US
Mailing Address - Phone:770-668-3130
Mailing Address - Fax:267-295-2834
Practice Address - Street 1:145 GOVENORS SQUARE
Practice Address - Street 2:STE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30269
Practice Address - Country:US
Practice Address - Phone:770-668-3130
Practice Address - Fax:267-295-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104588Medicaid