Healthcare Provider Details

I. General information

NPI: 1407112360
Provider Name (Legal Business Name): TODAY'S FAMILY TIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 BRIARWOOD CT
RIVERDALE GA
30296-2904
US

IV. Provider business mailing address

6439 BRIARWOOD CT
RIVERDALE GA
30296-2904
US

V. Phone/Fax

Practice location:
  • Phone: 404-433-0307
  • Fax:
Mailing address:
  • Phone: 404-433-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number12-00036428
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number12-00036428
License Number StateGA

VIII. Authorized Official

Name: MR. LARRY DEWITT FULLER JR.
Title or Position: COMMUNITY RESOURCE SPECIALIST
Credential: M.A
Phone: 404-433-0307