Provider Demographics
NPI:1700245891
Name:PERSONAL RECOVERY NETWORK LLC
Entity Type:Organization
Organization Name:PERSONAL RECOVERY NETWORK LLC
Other - Org Name:GEORGIA BEHAVIORAL HEALTH PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:NICHOLS
Authorized Official - Last Name:TAGTACHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-548-2589
Mailing Address - Street 1:250 CORPORATE CENTER CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6388
Mailing Address - Country:US
Mailing Address - Phone:770-389-8100
Mailing Address - Fax:770-389-3030
Practice Address - Street 1:250 CORPORATE CENTER CT
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6388
Practice Address - Country:US
Practice Address - Phone:770-389-8100
Practice Address - Fax:770-389-3030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERSONAL RECOVERY NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-17
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty