Provider Demographics
NPI:1285340406
Name:INTERVENTION SERVICES OF SOUTHEAST ALABAMA, LLC
Entity type:Organization
Organization Name:INTERVENTION SERVICES OF SOUTHEAST ALABAMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSYCA
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW-S
Authorized Official - Phone:334-406-0816
Mailing Address - Street 1:108 CREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-4474
Mailing Address - Country:US
Mailing Address - Phone:334-406-0816
Mailing Address - Fax:
Practice Address - Street 1:557 GLOVER AVE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2024
Practice Address - Country:US
Practice Address - Phone:334-308-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty