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General NPI Number Information
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NPI Number | 1841486305
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Entity Type | Organization
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Legal Business Name | GEORGIA YOUTH NETWORK INC
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 925 MAIN ST SUITE 104
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3098
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Country | US
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Telephone | 770-344-8704
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Fax | 770-216-1723
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Provider Business Mailing Address
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Address Line | PO BOX 82322
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City | CONYERS
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State | GA
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Zip | 30013-9434
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Country | US
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Telephone | 770-344-8704
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Fax | 770-216-1723
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. JANINE PORTER
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Credential |
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Telephone | 770-344-8704
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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 | NONE
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License Number State | GA
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