Basic Information
| Provider Information | |||||||||
| NPI: | 1437334372 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCONEE COMMUNITY SERVICE BOARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1827 | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310591827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784454817 | ||||||||
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| Practice Location | |||||||||
| Address1: | 824 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | SANDERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310827034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782403050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER SYSTEMS | ||||||||
| AuthorizedOfficialTelephone: | 4784454971 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00604469A | 05 | GA | MEDICAID |