Healthcare Provider Details

I. General information

NPI: 1336006196
Provider Name (Legal Business Name): INTERGENERATIONAL CHANGE BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 MORGAN BOX LN
BUFORD GA
30519-7569
US

IV. Provider business mailing address

3134 MORGAN BOX LN
BUFORD GA
30519-7569
US

V. Phone/Fax

Practice location:
  • Phone: 770-547-0105
  • Fax:
Mailing address:
  • Phone: 770-547-0105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ERRICK THORNTON
Title or Position: OWNER
Credential: LCSW, LMSW, MSW
Phone: 770-547-0105