Healthcare Provider Details

I. General information

NPI: 1336458991
Provider Name (Legal Business Name): FAMILY SUPPORT CIRCLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1479 TETHER LN
MCDONOUGH GA
30253-9209
US

IV. Provider business mailing address

1479 TETHER LN P.O.BOX 2439
MCDONOUGH GA
30253-9209
US

V. Phone/Fax

Practice location:
  • Phone: 770-378-4070
  • Fax:
Mailing address:
  • Phone: 770-378-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. ELNA JEANTINE
Title or Position: PRESIDENT/FOUNDER
Credential: ED.D.
Phone: 770-378-4070