Provider Demographics
NPI:1396097093
Name:GRACE HARBOUR INC. BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:GRACE HARBOUR INC. BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:678-326-4488
Mailing Address - Street 1:2 LEE ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1915
Mailing Address - Country:US
Mailing Address - Phone:678-326-4488
Mailing Address - Fax:678-669-2693
Practice Address - Street 1:2 LEE ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1915
Practice Address - Country:US
Practice Address - Phone:678-326-4488
Practice Address - Fax:678-669-2693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149839251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1407072770OtherGRACE HARBOUR NPI NUMBER