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General NPI Number Information
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NPI Number | 1114273315
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Entity Type | Organization
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Legal Business Name | FRESH START COMMUNITY DEVELOPERS, LLC
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Dates
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Enumeration Date | 07/25/2012
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Last Update Date | 07/25/2012
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Provider Practice Location Address
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Address Line | 46 SYCAMORE STA
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City | DECATUR
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State | GA
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Zip | 30030-2757
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Country | US
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Telephone | 404-245-9265
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Fax | 404-370-1202
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Provider Business Mailing Address
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Address Line | 46 SYCAMORE STA
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City | DECATUR
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State | GA
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Zip | 30030-2757
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Country | US
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Telephone | 404-245-9265
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Fax | 404-370-1202
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Authorized Official
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Title or Position | CERTIFIED ADDICTION COUNSELOR
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Name | MR. KIRK MICHAEL WILLIAMS
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Credential | MS, CADC, ICRC, SAM
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Telephone | 404-245-9265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 236
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License Number State | GA
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