=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013208651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANT SERVICES FOR THE DISABLED , INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2011
-----------------------------------------------------
Last Update Date | 05/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1603 HIDDEN HILLS PKWY
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30088-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-879-5507
-----------------------------------------------------
Fax | 678-691-4082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1603 HIDDEN HILLS PKWY
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30088-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-879-5507
-----------------------------------------------------
Fax | 678-691-4082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/CEO
-----------------------------------------------------
Name | MS. SHARON LEWIS MENTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-879-5507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 044-01-396-1
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------