Basic Information
| Provider Information | |||||||||
| NPI: | 1356795462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TMC-BEHAVIORAL HEALTH OF WEST GEORGIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BEHAVIORAL HEALTH OF WEST GEORGIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 706 DIXIE ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708125735 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 QUARTZ DR STE 103B | ||||||||
| Address2: | |||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301803201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708123530 | ||||||||
| FaxNumber: | 7708123531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2016 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAGSDALE | ||||||||
| AuthorizedOfficialFirstName: | JILLIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7708388710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.