MEDICARE: ECLECTICS

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	LPC009399	GA

General Provider Information

NPI Number	:	1225576796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECLECTICS

Provider Business Mailing Address
First Line	:	3846 TRASK DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31903-2937
Country	:	US
Telephone Number	:	706-566-3169
Fax Number	:

Provider Business Practice Location Address
First Line	:	3846 TRASK DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31903-2937
Country	:	US
Telephone Number	:	706-566-3169
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. ALFONZA ALLEN KING
Credential	:	MS, LPC
Telephone Number	:	706-566-3169

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	02/06/2017

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Directions to “ECLECTICS ” Practice Location

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