Healthcare Provider Details

I. General information

NPI: 1073997888
Provider Name (Legal Business Name): DEVEREUX GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 STANLEY RD NW
KENNESAW GA
30152-4359
US

IV. Provider business mailing address

1291 STANLEY RD NW
KENNESAW GA
30152-4359
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0147
  • Fax: 678-303-5256
Mailing address:
  • Phone: 770-427-0147
  • Fax: 678-303-5256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number1352
License Number StateGA

VIII. Authorized Official

Name: MS. CATHY SEARS HUFF
Title or Position: CLINICAL THERAPIST
Credential: LCSW
Phone: 770-427-0147