Healthcare Provider Details

I. General information

NPI: 1992014823
Provider Name (Legal Business Name): GREATER ATLANTA YOUTH DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 NORTH DR
FAYETTEVILLE GA
30214-2628
US

IV. Provider business mailing address

3305 ACWORTH OAKS DR NW SUITE #200-PMB#123
ACWORTH GA
30101-6693
US

V. Phone/Fax

Practice location:
  • Phone: 404-593-9613
  • Fax: 770-975-7732
Mailing address:
  • Phone: 404-593-9613
  • Fax: 770-975-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. WILLIAM JOSEPH THOMAS SR.
Title or Position: EXECUTIVE DIRECTOR
Credential: BA, MA
Phone: 404-593-9613