Provider Demographics
NPI:1700246550
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:MRS
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 1:4015 S COBB DR SE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6303
Mailing Address - Country:US
Mailing Address - Phone:770-431-2354
Mailing Address - Fax:770-436-7143
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:SUITE 115
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-431-2354
Practice Address - Fax:770-436-7143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERSONAL RECOVERY NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-07
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