Healthcare Provider Details

I. General information

NPI: 1962750869
Provider Name (Legal Business Name): FAMILIES FORWARD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 EXECUTIVE CENTER DR SUITE 101
MARTINEZ GA
30907-0951
US

IV. Provider business mailing address

3711 EXECUTIVE CENTER DR SUITE 101
MARTINEZ GA
30907-0951
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-8855
  • Fax: 678-541-7699
Mailing address:
  • Phone: 706-210-8855
  • Fax: 678-541-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY003096
License Number StateGA

VIII. Authorized Official

Name: DR. DARA A DELANCY
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 706-210-8855