Provider Demographics
NPI:1427425495
Name:DIVINE BEHAVIORAL SERVICES
Entity type:Organization
Organization Name:DIVINE BEHAVIORAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-234-9667
Mailing Address - Street 1:3781 PRESIDENTIAL PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-3702
Mailing Address - Country:US
Mailing Address - Phone:770-234-9667
Mailing Address - Fax:770-234-9668
Practice Address - Street 1:3781 PRESIDENTIAL PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3702
Practice Address - Country:US
Practice Address - Phone:770-234-9667
Practice Address - Fax:770-234-9668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160059AMedicaid