Provider Demographics
NPI:1851730089
Name:EATING DISORDER RECOVERY CENTER OF ATHENS, PC
Entity Type:Organization
Organization Name:EATING DISORDER RECOVERY CENTER OF ATHENS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEITZMAN SWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:706-552-0450
Mailing Address - Street 1:1 HUNTINGTON RD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7204
Mailing Address - Country:US
Mailing Address - Phone:706-552-0450
Mailing Address - Fax:706-850-7211
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:SUITE 801
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-552-0450
Practice Address - Fax:706-850-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002033251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003111010AMedicaid