Provider Demographics
NPI:1649652637
Name:CAPITAL CITY COMMUNITY SERVICES LLC
Entity type:Organization
Organization Name:CAPITAL CITY COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:FAMIKA
Authorized Official - Middle Name:LASHELL
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ICADC, SAP, NAM
Authorized Official - Phone:770-415-7200
Mailing Address - Street 1:5701 MABLETON PKWY
Mailing Address - Street 2:STE# 102
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2045
Mailing Address - Country:US
Mailing Address - Phone:770-415-7200
Mailing Address - Fax:470-689-0006
Practice Address - Street 1:5701 MABLETON PKWY
Practice Address - Street 2:STE# 102
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2045
Practice Address - Country:US
Practice Address - Phone:770-415-7200
Practice Address - Fax:470-689-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251300000X, 251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA CSAC-3058-ROtherGEORGIA ADDICTION COUNSELING ASSOCIATION
GADOT SAP# 20618OtherUS DEPARTMENT OF TRANSPORTATION
GA4567OtherNRC SUBSTANCE ABUSE EXPERT
GA4567OtherCISD TRAUMA SPECIALIST