Provider Demographics
NPI:1831831585
Name:STEP UP ON SECOND STREET, INC
Entity type:Organization
Organization Name:STEP UP ON SECOND STREET, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:TAVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-985-5250
Mailing Address - Street 1:1989 N WILLIAMSBURG DR STE A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3509
Mailing Address - Country:US
Mailing Address - Phone:470-462-3330
Mailing Address - Fax:
Practice Address - Street 1:1989 N WILLIAMSBURG DR STE A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3509
Practice Address - Country:US
Practice Address - Phone:470-462-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health