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General NPI Number Information
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NPI Number | 1346420619
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE PSYCHIATRIC CONSULTANTS
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Dates
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Enumeration Date | 11/05/2007
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Last Update Date | 11/21/2007
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Provider Practice Location Address
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Address Line | 990 E MAIN ST
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City | BLUE RIDGE
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State | GA
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Zip | 30513-4565
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Country | US
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Telephone | 706-258-2192
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Fax | 706-258-2193
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Provider Business Mailing Address
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Address Line | 990 E MAIN ST
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City | BLUE RIDGE
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State | GA
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Zip | 30513-4565
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Country | US
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Telephone | 706-258-2192
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Fax | 706-258-2193
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Authorized Official
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Title or Position | CEO
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Name | MICHAEL B GLADSON
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Credential | M.D.
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Telephone | 706-258-2192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 021506
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License Number State | GA
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