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General NPI Number Information
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NPI Number | 1316496425
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE MEDICAL BEHAVIORAL HEALTHCARE, LLC
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Dates
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Enumeration Date | 09/30/2016
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Last Update Date | 09/07/2018
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Provider Practice Location Address
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Address Line | 1842 INDEPENDENCE SQ STE D
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City | DUNWOODY
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State | GA
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Zip | 30338-5168
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Country | US
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Telephone | 404-643-9889
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Fax | 404-393-8389
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Provider Business Mailing Address
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Address Line | 1842 INDEPENDENCE SQ STE D
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City | DUNWOODY
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State | GA
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Zip | 30338-5168
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Country | US
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Telephone | 404-643-9889
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. MARCELLA E FULTON
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Credential | LCSW
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Telephone | 404-643-9889
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW002643
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License Number State | GA
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