Healthcare Provider Details

I. General information

NPI: 1144374604
Provider Name (Legal Business Name): CHILDREN'S BMH PROVIDERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2401
US

IV. Provider business mailing address

1575 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2401
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 404-785-7876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: RUTH FOWLER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 404-785-5437