Healthcare Provider Details

I. General information

NPI: 1447704804
Provider Name (Legal Business Name): THE TRANSFORMATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 HAMPTON XING
NORCROSS GA
30093-4060
US

IV. Provider business mailing address

416 HAMPTON XING
NORCROSS GA
30093-4060
US

V. Phone/Fax

Practice location:
  • Phone: 713-906-1350
  • Fax:
Mailing address:
  • Phone: 713-906-1350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JOHN D WALLACE
Title or Position: EXECUTIVE DIRECTOR
Credential: PSY.D
Phone: 713-906-1350