Healthcare Provider Details

I. General information

NPI: 1952562605
Provider Name (Legal Business Name): AFRICAN AMERICAN TASK FORCE FOR SUBSTANCE ABUSE PREVENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PERRY ST
NEWNAN GA
30263-1918
US

IV. Provider business mailing address

PO BOX 72001
NEWNAN GA
30271-2001
US

V. Phone/Fax

Practice location:
  • Phone: 678-423-3200
  • Fax:
Mailing address:
  • Phone: 678-423-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. EDITH RENEE BYRD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 678-423-3200