Provider Demographics
NPI:1700062437
Name:AMAZON SELF DEVELOPMENT, LLC
Entity Type:Organization
Organization Name:AMAZON SELF DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-432-3600
Mailing Address - Street 1:821 12TH SREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:706-432-3600
Mailing Address - Fax:706-432-3621
Practice Address - Street 1:821 12TH SREET
Practice Address - Street 2:SUITE B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2749
Practice Address - Country:US
Practice Address - Phone:706-432-3600
Practice Address - Fax:706-432-3621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005104251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health