Provider Demographics
NPI:1386704518
Name:BACK ON TRACK
Entity type:Organization
Organization Name:BACK ON TRACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-320-6906
Mailing Address - Street 1:1925 CENTURY BLVD NE
Mailing Address - Street 2:STE 8
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3315
Mailing Address - Country:US
Mailing Address - Phone:404-320-6906
Mailing Address - Fax:404-320-6907
Practice Address - Street 1:1925 CENTURY BLVD NE
Practice Address - Street 2:STE 8
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3315
Practice Address - Country:US
Practice Address - Phone:404-320-6906
Practice Address - Fax:404-320-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty