Provider Demographics
NPI:1821609389
Name:WIREGRASS BEHAVIORAL GROUP LLC
Entity Type:Organization
Organization Name:WIREGRASS BEHAVIORAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-792-6736
Mailing Address - Street 1:256 HONEYSUCKLE RD STE 12
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1168
Mailing Address - Country:US
Mailing Address - Phone:334-792-6736
Mailing Address - Fax:334-792-6737
Practice Address - Street 1:256 HONEYSUCKLE RD STE 12
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1168
Practice Address - Country:US
Practice Address - Phone:334-792-6736
Practice Address - Fax:334-792-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty