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General NPI Number Information
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NPI Number | 1083911267
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Entity Type | Organization
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Legal Business Name | FOOTPRINTS BEHAVIORAL SERVICES, LLC.
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Dates
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Enumeration Date | 02/23/2011
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Last Update Date | 02/23/2011
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Provider Practice Location Address
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Address Line | 111 W PINE ST
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City | VIDALIA
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State | GA
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Zip | 30474-3114
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Country | US
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Telephone | 912-537-0140
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Fax |
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Provider Business Mailing Address
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Address Line | 5205 MERRICK DR
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-6701
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | ERICKA BLOUNT
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Credential |
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Telephone | 678-490-1290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | GA
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