Healthcare Provider Details

I. General information

NPI: 1699136317
Provider Name (Legal Business Name): HOPE BEHAVIORAL HEALTH & ADDICTIVE DISEASE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 S MACARTHUR DR
CAMILLA GA
31730-7410
US

IV. Provider business mailing address

218 S MACARTHUR DR
CAMILLA GA
31730-7410
US

V. Phone/Fax

Practice location:
  • Phone: 229-336-1702
  • Fax: 229-336-1701
Mailing address:
  • Phone: 229-336-1702
  • Fax: 229-336-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: MS. SHUNTOL HARRIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 229-798-3929