Healthcare Provider Details

I. General information

NPI: 1497407506
Provider Name (Legal Business Name): BLACK SHEEP TRAUMA AND RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E MONROE ST
THOMASVILLE GA
31792-5142
US

IV. Provider business mailing address

125 E MONROE ST
THOMASVILLE GA
31792-5142
US

V. Phone/Fax

Practice location:
  • Phone: 404-860-2111
  • Fax:
Mailing address:
  • Phone: 678-577-8795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOHN WIDENER
Title or Position: OWNER
Credential: LPC, LMFT
Phone: 678-577-8795