Provider Demographics
NPI:1386806412
Name:TRIAD EP, PC
Entity type:Organization
Organization Name:TRIAD EP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-331-8760
Mailing Address - Street 1:316 ALEXANDER ST SE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2001
Mailing Address - Country:US
Mailing Address - Phone:770-331-8760
Mailing Address - Fax:678-581-0146
Practice Address - Street 1:316 ALEXANDER ST SE
Practice Address - Street 2:SUITE 6
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2001
Practice Address - Country:US
Practice Address - Phone:770-331-8760
Practice Address - Fax:678-581-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0027321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherAMERIGROUP