Provider Demographics
NPI:1306263967
Name:AGAPE WELLNESS AND FAMILY SERVICES
Entity type:Organization
Organization Name:AGAPE WELLNESS AND FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BAILEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:702-578-3035
Mailing Address - Street 1:6112 RIVEROAK TER
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4078
Mailing Address - Country:US
Mailing Address - Phone:770-580-0960
Mailing Address - Fax:702-974-1342
Practice Address - Street 1:7100 GRAND MONTECITO PKWY
Practice Address - Street 2:UNIT 3063
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-0282
Practice Address - Country:US
Practice Address - Phone:702-578-3035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16140110251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health