MEDICARE: BEHAVIORAL LEARNING NETWORK GEORGIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1215500632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEHAVIORAL LEARNING NETWORK GEORGIA LLC

Provider Business Mailing Address
First Line	:	75 RICHARDSON ST SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-2839
Country	:	US
Telephone Number	:	310-933-4499
Fax Number	:	310-933-4134

Provider Business Practice Location Address
First Line	:	75 RICHARDSON ST SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-2839
Country	:	US
Telephone Number	:	310-933-4499
Fax Number	:	310-933-4134

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. GREGORY ELSKY
Credential	:	PSY.D., LMFT, BCBAD
Telephone Number	:	310-933-4499

Provider Enumeration Date	:	07/22/2021
Last Update Date	:	07/22/2021

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