Basic Information
| Provider Information | |||||||||
| NPI: | 1144374604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS BMH PROVIDERS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDRENS BMH PROVIDERS, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 NORTHEAST EXPY NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1605 CHANTILLY DR NE STE 110 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303243277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047855437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATHIESON | ||||||||
| AuthorizedOfficialFirstName: | HAYDEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 4047850589 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.