Healthcare Provider Details

I. General information

NPI: 1659752491
Provider Name (Legal Business Name): BIG MAMA HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PENNYBROOK LN
STONE MOUNTAIN GA
30087-5918
US

IV. Provider business mailing address

707 PENNYBROOK LN
STONE MOUNTAIN GA
30087-5918
US

V. Phone/Fax

Practice location:
  • Phone: 404-538-6074
  • Fax:
Mailing address:
  • Phone: 404-538-6074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: HANNIYAH ABDUL AZIZ
Title or Position: CEO/OWNER
Credential:
Phone: 404-538-6074