Healthcare Provider Details

I. General information

NPI: 1861016537
Provider Name (Legal Business Name): BEHAVIORAL HEALTH PROFESSIONALS OF LAGRANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321B GREENVILLE ST
LAGRANGE GA
30241-3231
US

IV. Provider business mailing address

321B GREENVILLE ST
LAGRANGE GA
30241-3231
US

V. Phone/Fax

Practice location:
  • Phone: 706-616-1715
  • Fax: 706-637-2320
Mailing address:
  • Phone: 706-616-1715
  • Fax: 706-637-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICHOLAS MOSES
Title or Position: OWNER
Credential:
Phone: 706-616-1715