Provider Demographics
NPI:1699178301
Name:NORTHWEST GEORGIA BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:NORTHWEST GEORGIA BEHAVIORAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:770-712-0878
Mailing Address - Street 1:5150 STILESBORO RD. NW
Mailing Address - Street 2:SUITE 430
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152
Mailing Address - Country:US
Mailing Address - Phone:770-712-0878
Mailing Address - Fax:
Practice Address - Street 1:5150 STILESBORO RD NW
Practice Address - Street 2:SUITE 430
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7744
Practice Address - Country:US
Practice Address - Phone:770-712-0878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC03999101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty