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General NPI Number Information
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NPI Number | 1134355910
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Entity Type | Organization
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Legal Business Name | LIFE EVOLUTIONS BEHAVIORAL HEALTH CARE, LLC
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Dates
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Enumeration Date | 06/07/2009
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Last Update Date | 06/07/2009
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Provider Practice Location Address
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Address Line | 2598 N DECATUR RD
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City | DECATUR
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State | GA
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Zip | 30033-6118
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Country | US
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Telephone | 404-636-5346
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 83339
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City | CONYERS
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State | GA
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Zip | 30013-8019
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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 | OWNER/EXECUTIVE DIRECTOR
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Name | ATASHA MURRAY
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Credential |
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Telephone | 404-636-4346
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | SLP006065
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License Number State | GA
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