Healthcare Provider Details

I. General information

NPI: 1376019141
Provider Name (Legal Business Name): THE MARGIE REE HANSFORD THURMOND FAMILY LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KING RD
RIVERDALE GA
30274-2027
US

IV. Provider business mailing address

9100 AMBERLEIGH LN
RIVERDALE GA
30274-4682
US

V. Phone/Fax

Practice location:
  • Phone: 770-468-7100
  • Fax:
Mailing address:
  • Phone: 770-468-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. MYRNA THURMOND MALONE
Title or Position: CLINICAL DIRECTOR
Credential: CPC
Phone: 770-468-7100