=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528393592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILYS MATTER COUNSELING AND PSYCHOLOGICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2009
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4568 LAWRENCEVILLE HWY NW SUITE 201 C
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-602-0182
-----------------------------------------------------
Fax | 404-602-0069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4568 LAWRENCEVILLE HWY NW SUITE 201 C
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-602-0182
-----------------------------------------------------
Fax | 404-602-0069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. VICTOR T GRIMES
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 404-602-0182
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LPC004452
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------