Healthcare Provider Details

I. General information

NPI: 1174942684
Provider Name (Legal Business Name): DEPARTMENT OF BEHAVIORAL HEALTH & DEVELOPMENTAL DISABILITIES, GA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S PINETREE BLVD
THOMASVILLE GA
31792-7128
US

IV. Provider business mailing address

400 S PINETREE BLVD
THOMASVILLE GA
31792-7128
US

V. Phone/Fax

Practice location:
  • Phone: 229-227-2990
  • Fax: 229-225-4052
Mailing address:
  • Phone: 229-227-2990
  • Fax: 229-225-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number51452
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30647
License Number StateGA

VIII. Authorized Official

Name: DR. HOLLY M CROWLEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 229-227-2990