Healthcare Provider Details

I. General information

NPI: 1063765881
Provider Name (Legal Business Name): THE SOUTHERN CENTER FOR CHOICE THEORY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 PARK ST
MACON GA
31210-5017
US

IV. Provider business mailing address

144 PARK ST
MACON GA
31210-5017
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-7785
  • Fax: 478-477-7445
Mailing address:
  • Phone: 478-471-7785
  • Fax: 478-477-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC004607
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW003871
License Number StateGA

VIII. Authorized Official

Name: ANDREA CARRIMA COOKE
Title or Position: DEVELOPMENT DIRECTOR
Credential:
Phone: 478-471-7785