Healthcare Provider Details

I. General information

NPI: 1619424231
Provider Name (Legal Business Name): DEVEREUX GOERGIA TREATMENT NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 STANLEY RD
KENNESAW GA
30152
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:
Mailing address:
  • Phone: 770-427-0147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number0038001
License Number StateGA

VIII. Authorized Official

Name: DR. YOLANDA PATRICE GRAHAM
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 770-427-0147