Healthcare Provider Details

I. General information

NPI: 1598732869
Provider Name (Legal Business Name): SOUTHERN BEHAVIORAL HEALTHCARE,P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2006
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BRAXTON CT
FAYETTEVILLE GA
30214-1968
US

IV. Provider business mailing address

110 BRAXTON CT
FAYETTEVILLE GA
30214-1968
US

V. Phone/Fax

Practice location:
  • Phone: 678-610-7100
  • Fax: 678-610-7111
Mailing address:
  • Phone: 678-610-7100
  • Fax: 678-610-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number64622
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number051606
License Number StateGA

VIII. Authorized Official

Name: MRS. SALEWA TAIWO
Title or Position: OFFICE MANAGER
Credential:
Phone: 678-610-7100