Healthcare Provider Details

I. General information

NPI: 1518540715
Provider Name (Legal Business Name): CLOSER TO EDEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 CORNERSTONE PASS
CONYERS GA
30012-3788
US

IV. Provider business mailing address

1936 CORNERSTONE PASS
CONYERS GA
30012-3788
US

V. Phone/Fax

Practice location:
  • Phone: 732-331-4372
  • Fax:
Mailing address:
  • Phone: 678-825-5019
  • 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

VIII. Authorized Official

Name: RENEE BRYAN
Title or Position: CEO
Credential:
Phone: 732-331-4372