MEDICARE: INTERGENERATIONAL CHANGE BEHAVIORAL HEALTH SERVICES

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1336006196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERGENERATIONAL CHANGE BEHAVIORAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	3134 MORGAN BOX LN
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-7569
Country	:	US
Telephone Number	:	770-547-0105
Fax Number	:

Provider Business Practice Location Address
First Line	:	3134 MORGAN BOX LN
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-7569
Country	:	US
Telephone Number	:	770-547-0105
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ERRICK THORNTON
Credential	:	LCSW, LMSW, MSW
Telephone Number	:	770-547-0105

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	01/05/2026

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