Provider Demographics
NPI:1285271528
Name:VITALIS BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:VITALIS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-841-0500
Mailing Address - Street 1:3091 BATTLEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4003
Mailing Address - Country:US
Mailing Address - Phone:706-841-0500
Mailing Address - Fax:
Practice Address - Street 1:3091 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4003
Practice Address - Country:US
Practice Address - Phone:706-841-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health