Provider Demographics
NPI:1154794410
Name:GRANDMA'S PORCH FAMILY SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:GRANDMA'S PORCH FAMILY SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-607-5735
Mailing Address - Street 1:1466 COPELAND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2501
Mailing Address - Country:US
Mailing Address - Phone:202-250-9420
Mailing Address - Fax:
Practice Address - Street 1:3915 CASCADE RD SW
Practice Address - Street 2:SUITE T132
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8512
Practice Address - Country:US
Practice Address - Phone:678-607-5735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006401101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty