Provider Demographics
NPI:1881756104
Name:GRN COMMUNITY SERVICE BOARD
Entity type:Organization
Organization Name:GRN COMMUNITY SERVICE BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CSI COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:HADEN
Authorized Official - Last Name:RAPER
Authorized Official - Suffix:
Authorized Official - Credentials:MED, MS
Authorized Official - Phone:770-638-5760
Mailing Address - Street 1:3432 WATER VISTAS PKWY
Mailing Address - Street 2:APT. B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-3070
Mailing Address - Country:US
Mailing Address - Phone:770-381-5498
Mailing Address - Fax:
Practice Address - Street 1:5030 GEORGIA BELLE CT
Practice Address - Street 2:STE 2036
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2667
Practice Address - Country:US
Practice Address - Phone:770-638-5760
Practice Address - Fax:770-638-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health