Healthcare Provider Details

I. General information

NPI: 1891859377
Provider Name (Legal Business Name): GRN CSB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977A TAYLOR ST SW
CONYERS GA
30012-5357
US

IV. Provider business mailing address

977A TAYLOR ST SW
CONYERS GA
30012-5357
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-6677
  • Fax: 770-918-6686
Mailing address:
  • Phone: 770-918-6677
  • Fax: 770-918-6686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCSW003703
License Number StateGA

VIII. Authorized Official

Name: FALESHA ROBINSON
Title or Position: MENTAL HEALTH COUNSELOR
Credential:
Phone: 770-918-6677