=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457395733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVENIA BEHAVIORAL MANAGEMENT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 08/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 KARLS GATE DR
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30068-2017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-973-0687
-----------------------------------------------------
Fax | 770-973-3587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 MLK JR DR SW STE SUITES 418/420
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-564-4987
-----------------------------------------------------
Fax | 404-564-4988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RUSSELL E BROWN JR.
-----------------------------------------------------
Credential | M,D.
-----------------------------------------------------
Telephone | 404-316-4992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------