Provider Demographics
| NPI: | 1790818649 |
|---|---|
| Name: | THE IMARA CENTER,LC |
| Entity type: | Organization |
| Organization Name: | THE IMARA CENTER,LC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | MRS |
| Authorized Official - First Name: | SALA |
| Authorized Official - Middle Name: | I |
| Authorized Official - Last Name: | HILAIRE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | LCSW, MAC |
| Authorized Official - Phone: | 404-564-4796 |
| Mailing Address - Street 1: | 3915 CASCADE ROAD SW |
| Mailing Address - Street 2: | SUITE 205 |
| Mailing Address - City: | ATLANTA |
| Mailing Address - State: | GA |
| Mailing Address - Zip Code: | 30331-8522 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 404-564-4796 |
| Mailing Address - Fax: | 866-669-0494 |
| Practice Address - Street 1: | 3915 CASCADE ROAD SW |
| Practice Address - Street 2: | SUITE 205 |
| Practice Address - City: | ATLANTA |
| Practice Address - State: | GA |
| Practice Address - Zip Code: | 30331-8522 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 404-564-4796 |
| Practice Address - Fax: | 866-669-0494 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-03-13 |
| Last Update Date: | 2016-03-31 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| GA | CSW001980 | 101YM0800X, 101YP2500X, 103T00000X, 103TA0400X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TP2701X, 104100000X, 1041C0700X, 1041S0200X, 106H00000X, 101YA0400X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 1041S0200X | Behavioral Health & Social Service Providers | Social Worker | School | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| GA | 80BBFTQ | Medicaid | |
| GA | 931359420A | Medicare ID - Type Unspecified | # UNDER KAISER PERMANENTE |
| GA | 80BBFTQ | Medicaid |
