Provider Demographics
NPI:1770343584
Name:GEORGIA BEHAVIORAL CAMPUS LLC
Entity type:Organization
Organization Name:GEORGIA BEHAVIORAL CAMPUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-769-6594
Mailing Address - Street 1:211 GOOSE HOLLOW RD BLDG I
Mailing Address - Street 2:
Mailing Address - City:REYNOLDS
Mailing Address - State:GA
Mailing Address - Zip Code:31076-3505
Mailing Address - Country:US
Mailing Address - Phone:678-769-6594
Mailing Address - Fax:
Practice Address - Street 1:211 GOOSE HOLLOW RD BLDG I
Practice Address - Street 2:
Practice Address - City:REYNOLDS
Practice Address - State:GA
Practice Address - Zip Code:31076-3505
Practice Address - Country:US
Practice Address - Phone:678-769-6594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health