=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881968584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENLEE BEHAVIORAL HEALTH SERVICES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2012
-----------------------------------------------------
Last Update Date | 02/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 778 RAYS RD SUITE 102
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-298-1230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 778 RAYS RD SUITE 102
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-298-1230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MS. TIFFANY LASHA WIGGINS
-----------------------------------------------------
Credential | M.ED.
-----------------------------------------------------
Telephone | 404-298-1230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 453088947A
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------