MEDICARE: BUILDING INTIMATE MARRIAGES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	1970	GA
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1003943481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUILDING INTIMATE MARRIAGES, INC.

Provider Business Mailing Address
First Line	:	1325 SATELLITE BLVD NW
Second Line	:	SUITE 1002
City	:	SUWANEE
State	:	GA
Zip	:	30024-4651
Country	:	US
Telephone Number	:	770-822-4505
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 SATELLITE BLVD NW
Second Line	:	SUITE 1002
City	:	SUWANEE
State	:	GA
Zip	:	30024-4651
Country	:	US
Telephone Number	:	770-822-4505
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL SYTSMA
Credential	:
Telephone Number	:	770-822-4505

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	11/01/2016

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