Healthcare Provider Details

I. General information

NPI: 1750414439
Provider Name (Legal Business Name): GEORGIA THERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 CAMPBELLTON RD SW SUITE C-3
ATLANTA GA
30311-4455
US

IV. Provider business mailing address

2797 CAMPBELLTON RD SW SUITE C-3
ATLANTA GA
30311-4455
US

V. Phone/Fax

Practice location:
  • Phone: 404-349-6655
  • Fax: 404-349-0033
Mailing address:
  • Phone: 404-349-6655
  • Fax: 404-349-0033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberNTP001009
License Number StateGA

VIII. Authorized Official

Name: MR. TERRY L WILLIS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.S., CAS
Phone: 404-349-6655