MEDICARE: COLLECTIVE LEARNING ACADEMY, INC.

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1265154389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLECTIVE LEARNING ACADEMY, INC.

Provider Business Mailing Address
First Line	:	2715 PEACHTREE RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2907
Country	:	US
Telephone Number	:	404-721-0079
Fax Number	:

Provider Business Practice Location Address
First Line	:	2715 PEACHTREE RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-2907
Country	:	US
Telephone Number	:	404-721-0079
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LAURA DEISLEY
Credential	:
Telephone Number	:	404-721-0079

Provider Enumeration Date	:	09/15/2022
Last Update Date	:	09/15/2022

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