Provider Demographics
NPI:1538438742
Name:MENTOR ONE
Entity type:Organization
Organization Name:MENTOR ONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAVETA
Authorized Official - Middle Name:SYLVONYA
Authorized Official - Last Name:FUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MA, BA
Authorized Official - Phone:404-838-7903
Mailing Address - Street 1:PO BOX 1806
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1172
Mailing Address - Country:US
Mailing Address - Phone:404-838-7903
Mailing Address - Fax:678-324-6869
Practice Address - Street 1:4291 CAROLINE CT
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8227
Practice Address - Country:US
Practice Address - Phone:404-838-7903
Practice Address - Fax:678-324-6869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA00077528324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility