Basic Information
| Provider Information | |||||||||
| NPI: | 1275677098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCONEE COMMUNITY SERVICE BOARD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OCONEE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1241A ORCHARD HILL RD | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310612549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784454817 | ||||||||
| FaxNumber: | 4784454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 1241A ORCHARD HILL RD | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310612549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784454817 | ||||||||
| FaxNumber: | 4784454963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GHEESLING | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4784454971 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00605569P | 05 | GA | MEDICAID | 00604469J | 05 | GA | MEDICAID | 00604469Y | 05 | GA | MEDICAID | 00603424K | 05 | GA | MEDICAID | 099987674A | 05 | GA | MEDICAID | 00603424B | 05 | GA | MEDICAID | 00603424F | 05 | GA | MEDICAID | 00604469F | 05 | GA | MEDICAID | 00604469U | 05 | GA | MEDICAID | 00925339A | 05 | GA | MEDICAID | 00604469B | 05 | GA | MEDICAID | 00604469Q | 05 | GA | MEDICAID | 00604469I | 05 | GA | MEDICAID | 00604469N | 05 | GA | MEDICAID | 00604469Z | 05 | GA | MEDICAID | 00611223A | 05 | GA | MEDICAID | 16-728-5282 | 01 | GA | D-U-N-S | OTHER |