Healthcare Provider Details

I. General information

NPI: 1235793241
Provider Name (Legal Business Name): MESEPP COMMUNITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 EATONTON ST
MONTICELLO GA
31064-1029
US

IV. Provider business mailing address

825 EATONTON ST
MONTICELLO GA
31064-1029
US

V. Phone/Fax

Practice location:
  • Phone: 404-543-4497
  • Fax:
Mailing address:
  • Phone: 404-543-4497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH LONDON
Title or Position: CEO
Credential: MS, LPC, MAC
Phone: 404-543-4497