MEDICARE: MENTORING AND BEHAVIORAL 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	251S00000X	Community/Behavioral Health Agency	108544	GA

General Provider Information

NPI Number	:	1689939076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTORING AND BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	7000 STORAGE CT
Second Line	:	SUITE 22
City	:	COLUMBUS
State	:	GA
Zip	:	31907-0700
Country	:	US
Telephone Number	:	706-587-8986
Fax Number	:	706-221-5819

Provider Business Practice Location Address
First Line	:	7000 STORAGE CT
Second Line	:	SUITE 22
City	:	COLUMBUS
State	:	GA
Zip	:	31907-0700
Country	:	US
Telephone Number	:	706-587-8986
Fax Number	:	706-221-5819

Authorized Official
Title or Position	:	OWNER
Name	:	PAULINE HENRY
Credential	:
Telephone Number	:	706-587-8986

Provider Enumeration Date	:	07/11/2012
Last Update Date	:	07/11/2012

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