Basic Information
| Provider Information | |||||||||
| NPI: | 1508169400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CSB OF MIDDLE GEORGIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY MENTAL HEALTH CENTER OF MIDDLE GA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782756649 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121-A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782756649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | PATSY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4782721190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ED.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | RN126651 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000606284H | 05 | GA | MEDICAID |