Healthcare Provider Details

I. General information

NPI: 1568339554
Provider Name (Legal Business Name): GREATER GEORGIA BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CARNEGIE PL
FAYETTEVILLE GA
30214-3905
US

IV. Provider business mailing address

1600 PROVIDENCE HWY STE 100
WALPOLE MA
02081-2557
US

V. Phone/Fax

Practice location:
  • Phone: 470-435-8028
  • Fax:
Mailing address:
  • Phone: 470-435-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MATT DINICOLA
Title or Position: MEMBER
Credential:
Phone: 781-472-0247