Provider Demographics
NPI:1861861361
Name:CHILD, YOUTH, ADOLESCENTS, AND FAMILIES
Entity Type:Organization
Organization Name:CHILD, YOUTH, ADOLESCENTS, AND FAMILIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:ELANTA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:770-478-2640
Mailing Address - Street 1:1396 SOUTHLAKE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1756
Mailing Address - Country:US
Mailing Address - Phone:770-473-2640
Mailing Address - Fax:770-473-2601
Practice Address - Street 1:1396 SOUTHLAKE PLAZA DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1756
Practice Address - Country:US
Practice Address - Phone:770-473-2640
Practice Address - Fax:770-473-2601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEHAVIORAL HEALTH DERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN228517310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness