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General NPI Number Information
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NPI Number | 1497046882
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Entity Type | Organization
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Legal Business Name | GRN CSB
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Dates
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Enumeration Date | 04/20/2011
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Last Update Date | 04/20/2011
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Provider Practice Location Address
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Address Line | 490 S PERRY ST
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4837
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Country | US
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Telephone | 770-339-2321
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Fax |
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Provider Business Mailing Address
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Address Line | 490 S PERRY ST
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4837
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Country | US
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Telephone | 770-339-2321
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Fax |
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Authorized Official
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Title or Position | CLINICIAN
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Name | MR. JACK E UNDERWOOD JR.
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Credential | LAPC
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Telephone | 770-339-2259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | APC002422
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License Number State | GA
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