=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649652637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL CITY COMMUNITY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 03/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 MABLETON PKWY STE# 102
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-415-7200
-----------------------------------------------------
Fax | 470-689-0006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5701 MABLETON PKWY STE# 102
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-415-7200
-----------------------------------------------------
Fax | 470-689-0006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | PROF. FAMIKA LASHELL ROBERTSON
-----------------------------------------------------
Credential | PHD, ICADC, SAP, NAM
-----------------------------------------------------
Telephone | 770-415-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------