Provider Demographics
NPI:1831947019
Name:BE FANTASTIC LLC
Entity type:Organization
Organization Name:BE FANTASTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-630-5859
Mailing Address - Street 1:PO BOX 1451
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-1451
Mailing Address - Country:US
Mailing Address - Phone:404-630-5859
Mailing Address - Fax:
Practice Address - Street 1:2302 PARKLAKE DR NE STE 511
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2974
Practice Address - Country:US
Practice Address - Phone:404-630-5859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty