Provider Demographics
NPI:1669700837
Name:ELLIJAY CENTER FOR CHANGE, PC
Entity type:Organization
Organization Name:ELLIJAY CENTER FOR CHANGE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:706-698-2400
Mailing Address - Street 1:89 HOSPITAL CIR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-9669
Mailing Address - Country:US
Mailing Address - Phone:706-698-2400
Mailing Address - Fax:706-698-2401
Practice Address - Street 1:89 HOSPITAL CIR
Practice Address - Street 2:SUITE 8
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-9669
Practice Address - Country:US
Practice Address - Phone:706-698-2400
Practice Address - Fax:706-698-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW001990101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty