Basic Information
| Provider Information | |||||||||
| NPI: | 1891859377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRN CSB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 977A TAYLOR ST SW | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300125357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709186677 | ||||||||
| FaxNumber: | 7709186686 | ||||||||
| Practice Location | |||||||||
| Address1: | 977A TAYLOR ST SW | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300125357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709186677 | ||||||||
| FaxNumber: | 7709186686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | FALESHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7709186677 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CSW003703 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.