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General NPI Number Information
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NPI Number | 1063765881
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Entity Type | Organization
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Legal Business Name | THE SOUTHERN CENTER FOR CHOICE THEORY, LLC
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Dates
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Enumeration Date | 10/17/2012
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Last Update Date | 10/17/2012
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Provider Practice Location Address
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Address Line | 144 PARK ST
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City | MACON
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State | GA
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Zip | 31210-5017
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Country | US
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Telephone | 478-471-7785
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Fax | 478-477-7445
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Provider Business Mailing Address
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Address Line | 144 PARK ST
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City | MACON
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State | GA
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Zip | 31210-5017
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Country | US
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Telephone | 478-471-7785
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Fax | 478-477-7445
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Authorized Official
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Title or Position | DEVELOPMENT DIRECTOR
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Name | ANDREA CARRIMA COOKE
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Credential |
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Telephone | 478-471-7785
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | MSW003871
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC004607
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License Number State | GA
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