Provider Demographics
NPI:1891362877
Name:SUPPORTIVE CARE OF GEORGIA LLC
Entity Type:Organization
Organization Name:SUPPORTIVE CARE OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTSCHEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-298-4375
Mailing Address - Street 1:27 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-8611
Mailing Address - Country:US
Mailing Address - Phone:718-298-4375
Mailing Address - Fax:
Practice Address - Street 1:300 COLONIAL CENTER PKWY STE 100N
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4892
Practice Address - Country:US
Practice Address - Phone:718-298-4375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty