Provider Demographics
NPI:1730228461
Name:MAGELLAN BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:MAGELLAN BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:678-319-3799
Mailing Address - Street 1:3970 N INDIAN CIR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5008
Mailing Address - Country:US
Mailing Address - Phone:678-319-3759
Mailing Address - Fax:314-292-1286
Practice Address - Street 1:3970 N INDIAN CIR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5008
Practice Address - Country:US
Practice Address - Phone:678-319-3759
Practice Address - Fax:314-292-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN091291305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service