Healthcare Provider Details

I. General information

NPI: 1508372244
Provider Name (Legal Business Name): FIRST STEP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 PARKER RD SE BLDG C
CONYERS GA
30094-6654
US

IV. Provider business mailing address

115 CLEAR SPRING LN
OXFORD GA
30054-4628
US

V. Phone/Fax

Practice location:
  • Phone: 770-728-1888
  • Fax: 770-728-1888
Mailing address:
  • Phone: 770-853-1352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LATOSHA PRESCOTT-CARR
Title or Position: OFFICER
Credential:
Phone: 770-853-1352