Basic Information
| Provider Information | |||||||||
| NPI: | 1164961876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER EDGE BEHAVIORAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788037600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 281 CARL VINSON PKWY | ||||||||
| Address2: | SUITE D | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310885824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788037899 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2017 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | NUNEZ | ||||||||
| AuthorizedOfficialFirstName: | MIRANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CCO | ||||||||
| AuthorizedOfficialTelephone: | 4788037758 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.