Healthcare Provider Details

I. General information

NPI: 1932479755
Provider Name (Legal Business Name): REBIRTH COUNSELING AND TRAINING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 03/05/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 S MARTIN ST STE 100
EAST POINT GA
30344-4396
US

IV. Provider business mailing address

3120 S MARTIN ST STE 100
EAST POINT GA
30344-4396
US

V. Phone/Fax

Practice location:
  • Phone: 678-705-5698
  • Fax:
Mailing address:
  • Phone: 404-867-3093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN HARPE WALLER
Title or Position: EXECUTIVE DIRECTOR
Credential: EDS.
Phone: 404-867-3093