Healthcare Provider Details

I. General information

NPI: 1497046882
Provider Name (Legal Business Name): GRN CSB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 S PERRY ST
LAWRENCEVILLE GA
30046-4837
US

IV. Provider business mailing address

490 S PERRY ST
LAWRENCEVILLE GA
30046-4837
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-2321
  • Fax:
Mailing address:
  • Phone: 770-339-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberAPC002422
License Number StateGA

VIII. Authorized Official

Name: MR. JACK E UNDERWOOD JR.
Title or Position: CLINICIAN
Credential: LAPC
Phone: 770-339-2259