Provider Demographics
NPI:1669605127
Name:THE FAMILY CENTER OF GEORGIA, INC.
Entity type:Organization
Organization Name:THE FAMILY CENTER OF GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HALISI
Authorized Official - Middle Name:EDWARDS
Authorized Official - Last Name:STATEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-768-1214
Mailing Address - Street 1:6964 HARBOR TOWN WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5467
Mailing Address - Country:US
Mailing Address - Phone:770-484-8834
Mailing Address - Fax:
Practice Address - Street 1:2520 HOLLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4424
Practice Address - Country:US
Practice Address - Phone:770-484-8834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0067101YA0400X
GAPSY002858103TF0000X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA86355324DMedicaid