Basic Information
| Provider Information | |||||||||
| NPI: | 1003358839 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLAND RIVERS CSB | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GORDON HOME AGAIN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 APPLEWOOD DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705000 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307011943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705000 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2016 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DALLAS | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7062705000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIGHLAND RIVERS COMMUNITY SERVICE BOARD | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPC, CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.