Provider Demographics
NPI:1063765881
Name:THE SOUTHERN CENTER FOR CHOICE THEORY, LLC
Entity type:Organization
Organization Name:THE SOUTHERN CENTER FOR CHOICE THEORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:CARRIMA
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-471-7785
Mailing Address - Street 1:144 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5017
Mailing Address - Country:US
Mailing Address - Phone:478-471-7785
Mailing Address - Fax:478-477-7445
Practice Address - Street 1:144 PARK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5017
Practice Address - Country:US
Practice Address - Phone:478-471-7785
Practice Address - Fax:478-477-7445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW003871104100000X
GALPC004607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty