Healthcare Provider Details

I. General information

NPI: 1942610845
Provider Name (Legal Business Name): ADDICTION RECOVERY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SMITH ST STE #1
LAGRANGE GA
30240-2780
US

IV. Provider business mailing address

100 SMITH ST STE #1
LAGRANGE GA
30240-2780
US

V. Phone/Fax

Practice location:
  • Phone: 706-594-4735
  • Fax: 706-243-4701
Mailing address:
  • Phone: 706-594-4735
  • Fax: 706-243-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number012692
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC003428
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC002077
License Number StateGA

VIII. Authorized Official

Name: WAYDE J WASHBURN
Title or Position: OWNER/COUNSELOR
Credential: CAC II
Phone: 706-594-4735