Healthcare Provider Details

I. General information

NPI: 1265161053
Provider Name (Legal Business Name): AGAPE COMMUNITY INTEGRATED HEALTH SYSTEMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5536 OLD NATIONAL HWY STE 100
COLLEGE PARK GA
30349-5181
US

IV. Provider business mailing address

5536 OLD NATIONAL HWY STE 100
COLLEGE PARK GA
30349-5181
US

V. Phone/Fax

Practice location:
  • Phone: 404-564-4796
  • Fax: 404-564-6487
Mailing address:
  • Phone: 404-564-6486
  • Fax: 404-564-6487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: AISHA FRAZIER
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 404-564-6486