Provider Demographics
NPI:1821223074
Name:CSI BEHAVIORAL COMPANY LLC
Entity Type:Organization
Organization Name:CSI BEHAVIORAL COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANGELA
Authorized Official - Middle Name:JAWAN
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-278-6979
Mailing Address - Street 1:1528 TELFAIR ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3908
Mailing Address - Country:US
Mailing Address - Phone:478-304-1244
Mailing Address - Fax:478-304-1254
Practice Address - Street 1:1528 TELFAIR ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3908
Practice Address - Country:US
Practice Address - Phone:478-304-1244
Practice Address - Fax:478-304-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA827333708AMedicaid