=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235531047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COBB COUNTY C.U.T.I.E.S, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2014
-----------------------------------------------------
Last Update Date | 09/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3961 FLOYD RD SUITE 300158
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-8535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-785-7284
-----------------------------------------------------
Fax | 770-438-7929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3961 FLOYD RD SUITE 300158
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-8535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-785-7284
-----------------------------------------------------
Fax | 770-438-7929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DANICE WILSON
-----------------------------------------------------
Credential | PRACTITIONER//MED
-----------------------------------------------------
Telephone | 678-785-7284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------