Healthcare Provider Details

I. General information

NPI: 1144972357
Provider Name (Legal Business Name): GREENLEAF OUTREACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12461 VETERANS MEMORIAL HWY STE 778
DOUGLASVILLE GA
30134-2025
US

IV. Provider business mailing address

12461 VETERANS MEMORIAL HWY STE 778
DOUGLASVILLE GA
30134-2025
US

V. Phone/Fax

Practice location:
  • Phone: 470-977-2747
  • Fax: 472-427-5443
Mailing address:
  • Phone: 470-977-2747
  • Fax: 470-427-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: NATYSHIA SMITH
Title or Position: DIRECTOR
Credential: MSW
Phone: 470-977-2747