Healthcare Provider Details

I. General information

NPI: 1790257426
Provider Name (Legal Business Name): FIRST STEP SOBER LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 MOUNT VERNON RD STE 200-A
ATLANTA GA
30338-4251
US

IV. Provider business mailing address

1742 MOUNT VERNON RD STE 150-B
ATLANTA GA
30338-4251
US

V. Phone/Fax

Practice location:
  • Phone: 470-307-9493
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: STEPHANIA RIVERA
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 470-370-9493