Provider Demographics
NPI:1700070398
Name:CELINE'S FAMILY SERVICE, INC
Entity Type:Organization
Organization Name:CELINE'S FAMILY SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-315-5146
Mailing Address - Street 1:1417 DOE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6203
Mailing Address - Country:US
Mailing Address - Phone:770-315-5146
Mailing Address - Fax:
Practice Address - Street 1:6440 OLD HILLANDALE DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7672
Practice Address - Country:US
Practice Address - Phone:770-315-5146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4279373712500320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA835780359AMedicaid