Basic Information
| Provider Information | |||||||||
| NPI: | 1811264088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATHERING PRECIOUS STONES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 903 PAVILION COURT /SUITE D | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049139114 | ||||||||
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| Practice Location | |||||||||
| Address1: | 903 PAVILION COURT | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049139114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4049139114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251S00000X | N | Agencies | Community/Behavioral Health | 305R00000X | N | Managed Care Organizations | Preferred Provider Organization | 305S00000X | N | Managed Care Organizations | Point of Service | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | 003149794A | 05 | GA | MEDICAID |