Healthcare Provider Details

I. General information

NPI: 1790204204
Provider Name (Legal Business Name): CASE SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 09/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4272 SUBLIME TRL
ATLANTA GA
30349-8883
US

IV. Provider business mailing address

2396 PENDERGRASS LN
ELLENWOOD GA
30294-6249
US

V. Phone/Fax

Practice location:
  • Phone: 484-459-6813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC007441
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLPC007441
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLPC007441
License Number StateGA

VIII. Authorized Official

Name: SHAUN B LEWIS
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential:
Phone: 484-459-6813