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General NPI Number Information
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NPI Number | 1407112360
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Entity Type | Organization
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Legal Business Name | TODAY'S FAMILY TIES
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Dates
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Enumeration Date | 04/04/2012
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Last Update Date | 04/04/2012
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Provider Practice Location Address
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Address Line | 6439 BRIARWOOD CT
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City | RIVERDALE
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State | GA
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Zip | 30296-2904
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Country | US
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Telephone | 404-433-0307
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Fax |
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Provider Business Mailing Address
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Address Line | 6439 BRIARWOOD CT
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City | RIVERDALE
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State | GA
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Zip | 30296-2904
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Country | US
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Telephone | 404-433-0307
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Fax |
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Authorized Official
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Title or Position | COMMUNITY RESOURCE SPECIALIST
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Name | MR. LARRY DEWITT FULLER JR.
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Credential | M.A
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Telephone | 404-433-0307
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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 | 12-00036428
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 12-00036428
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License Number State | GA
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