Healthcare Provider Details

I. General information

NPI: 1487792396
Provider Name (Legal Business Name): LITTLE DEBBIE'S SECOND CHANCE HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 LEPRECHAUN CT
DECATUR GA
30034-2168
US

IV. Provider business mailing address

3900 LEPRECHAUN CT
DECATUR GA
30034-2168
US

V. Phone/Fax

Practice location:
  • Phone: 770-912-3742
  • Fax: 404-288-0671
Mailing address:
  • Phone: 770-912-3742
  • Fax: 404-288-0671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCC1001625
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA

VIII. Authorized Official

Name: MS. LAKISHA SHAVON STIGGERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 770-912-3742