Provider Demographics
NPI:1932512621
Name:PROJECT REAL LIFE YOUTH OCCUPATIONAL TRAINING CORPS, INC.
Entity Type:Organization
Organization Name:PROJECT REAL LIFE YOUTH OCCUPATIONAL TRAINING CORPS, INC.
Other - Org Name:PROJECT REAL LIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ECHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-755-1730
Mailing Address - Street 1:6805 TARA BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1501
Mailing Address - Country:US
Mailing Address - Phone:770-464-6184
Mailing Address - Fax:
Practice Address - Street 1:6805 TARA BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1501
Practice Address - Country:US
Practice Address - Phone:770-464-6184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of Service
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty