Provider Demographics
NPI:1265941066
Name:CATALYST FOR CHANGE ATLANTA, LLC
Entity type:Organization
Organization Name:CATALYST FOR CHANGE ATLANTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIKAELA
Authorized Official - Middle Name:N
Authorized Official - Last Name:HEARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-748-0128
Mailing Address - Street 1:107 SHADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4129
Mailing Address - Country:US
Mailing Address - Phone:770-771-9000
Mailing Address - Fax:
Practice Address - Street 1:2801 BUFORD HWY NE STE 501
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2137
Practice Address - Country:US
Practice Address - Phone:678-748-0128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007304261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)