Provider Demographics
NPI:1215357272
Name:PROVIDENCE RESIDENTIAL & OUTPATIENT PTSD SERVICES, LLC
Entity type:Organization
Organization Name:PROVIDENCE RESIDENTIAL & OUTPATIENT PTSD SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY-MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-577-7873
Mailing Address - Street 1:6576 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1884
Mailing Address - Country:US
Mailing Address - Phone:770-577-7873
Mailing Address - Fax:770-577-7871
Practice Address - Street 1:6576 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1884
Practice Address - Country:US
Practice Address - Phone:770-577-7873
Practice Address - Fax:770-577-7871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YP2500X, 104100000X, 1041C0700X, 106H00000X, 133N00000X, 136A00000X, 163WP0808X, 164W00000X, 171100000X, 171M00000X, 2084P0800X, 374700000X
GAPSY003237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No374700000XNursing Service Related ProvidersTechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132073BMedicaid
GA003132073BMedicaid