=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750619177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSITIVE DIRECTIONS COUNSELING & BEHAVIORAL HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2009
-----------------------------------------------------
Last Update Date | 02/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4282 MEMORIAL DR STE C
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30032-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-319-2631
-----------------------------------------------------
Fax | 770-681-0643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3130 CHRISTOPHERS BND
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. CORTIM MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-319-2631
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------