Provider Demographics
NPI:1740320290
Name:SOUTH GEORGIA CSB
Entity type:Organization
Organization Name:SOUTH GEORGIA CSB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GUPTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT,LPC
Authorized Official - Phone:229-671-6101
Mailing Address - Street 1:3120 N OAK STREET EXT
Mailing Address - Street 2:SUITE C
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1007
Mailing Address - Country:US
Mailing Address - Phone:229-671-6140
Mailing Address - Fax:229-333-5263
Practice Address - Street 1:3120 N OAK STREET EXT
Practice Address - Street 2:SUITE C
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1007
Practice Address - Country:US
Practice Address - Phone:229-671-6140
Practice Address - Fax:229-333-5263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD1600X
GA261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health