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General NPI Number Information
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NPI Number | 1871634824
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Entity Type | Organization
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Legal Business Name | UNDERDUE SOCIAL SERVICES
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 12/14/2010
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Provider Practice Location Address
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Address Line | 165 BURKE ST SUITE 109
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-3463
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Country | US
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Telephone | 770-389-9886
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Fax |
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Provider Business Mailing Address
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Address Line | 1071 LAUREL RIDGE DR
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City | MCDONOUGH
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State | GA
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Zip | 30252-8432
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Country | US
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Telephone | 678-851-9509
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MISS KIMBERLY UNDERDUE
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Credential | LCSW
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Telephone | 770-389-9886
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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 |
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License Number State |
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