Basic Information
Provider Information | |||||||||
NPI: | 1801956883 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVER EDGE BEHAVIORAL HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OVERLOOK 1 | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 GRAY HWY | ||||||||
Address2: | APT. 604 | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312111901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787514519 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1400 GRAY HWY | ||||||||
Address2: | APT. 604 | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312111901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787514519 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TYLER | ||||||||
AuthorizedOfficialFirstName: | EMILY | ||||||||
AuthorizedOfficialMiddleName: | BETH | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 4787523231 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | GA | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.