Healthcare Provider Details

I. General information

NPI: 1659023604
Provider Name (Legal Business Name): DOUGLASVILLE ISLAMIC WOMEN'S SHELTER AND SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 WYNFORD LN
DOUGLASVILLE GA
30134-8012
US

IV. Provider business mailing address

8486 CAMPBELLTON ST #244
DOUGLASVILLE GA
30133
US

V. Phone/Fax

Practice location:
  • Phone: 704-427-5400
  • Fax: 470-427-5443
Mailing address:
  • Phone: 470-427-5400
  • Fax: 470-427-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. NATYSHIA SMITH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: BSW, MSW
Phone: 470-427-5440