Provider Demographics
NPI:1700195344
Name:EXTRAORDINARY BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:EXTRAORDINARY BEHAVIORAL SERVICES
Other - Org Name:EBS COUNSELING
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TORI
Authorized Official - Middle Name:HATTER
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:678-221-8494
Mailing Address - Street 1:500 MOUNTAINBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2853
Mailing Address - Country:US
Mailing Address - Phone:678-221-8494
Mailing Address - Fax:832-383-9718
Practice Address - Street 1:235 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3452
Practice Address - Country:US
Practice Address - Phone:678-221-8494
Practice Address - Fax:832-383-9718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health