Healthcare Provider Details

I. General information

NPI: 1891132486
Provider Name (Legal Business Name): FAMILY AND YOUTH INTERVENTION SPECIALIST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 SILVER MOON TRL
LITHIA SPRINGS GA
30122-3969
US

IV. Provider business mailing address

1206 SILVER MOON TRL
LITHIA SPRINGS GA
30122-3969
US

V. Phone/Fax

Practice location:
  • Phone: 404-259-9737
  • Fax: 678-398-3396
Mailing address:
  • Phone: 404-259-9737
  • Fax: 678-398-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JOSEPH OSONDU
Title or Position: CEO
Credential:
Phone: 404-259-9737