Healthcare Provider Details

I. General information

NPI: 1649482795
Provider Name (Legal Business Name): INSTITUTE FOR FAMILY SYSTEMS SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 WEST COLLINS AVE
LAKE PARK GA
31636
US

IV. Provider business mailing address

308 WEST COLLINS AVE
LAKE PARK GA
31636
US

V. Phone/Fax

Practice location:
  • Phone: 229-559-8597
  • Fax: 229-559-7760
Mailing address:
  • Phone: 229-559-8597
  • Fax: 229-559-7760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW000179
License Number StateGA

VIII. Authorized Official

Name: MR. EDWARD E SANDERS JR.
Title or Position: DIRECTOR
Credential: LMSW
Phone: 229-559-8597