Provider Demographics
NPI:1548497696
Name:BEHAVIORAL COUNSELING AND INTERVENTION MANAGEMENT, LLC
Entity type:Organization
Organization Name:BEHAVIORAL COUNSELING AND INTERVENTION MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MINCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-275-7854
Mailing Address - Street 1:787 OLD MACON RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-0941
Mailing Address - Country:US
Mailing Address - Phone:478-274-9003
Mailing Address - Fax:478-275-1916
Practice Address - Street 1:511 TELFAIR ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5144
Practice Address - Country:US
Practice Address - Phone:478-274-9003
Practice Address - Fax:478-275-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003234101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty