Provider Demographics
NPI:1841486305
Name:GEORGIA YOUTH NETWORK INC
Entity type:Organization
Organization Name:GEORGIA YOUTH NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-344-8704
Mailing Address - Street 1:PO BOX 82322
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-9434
Mailing Address - Country:US
Mailing Address - Phone:770-344-8704
Mailing Address - Fax:770-216-1723
Practice Address - Street 1:925 MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3098
Practice Address - Country:US
Practice Address - Phone:770-344-8704
Practice Address - Fax:770-216-1723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANONE251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health