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700 Westpark Dr Ste 200 Peachtree City GA 30269-3554 | |
| (770) 912-0898 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 700 Westpark Dr Ste 200, Peachtree City, Georgia |
| Authorized Official Name and Position | Damilola Mohammed (COO) |
| Authorized Official Contact | 9044404962 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
700 Westpark Dr Ste 200 Peachtree City GA 30269-1620 Ph: () - | 700 Westpark Dr Ste 200 Peachtree City GA 30269-3554 Ph: (770) 912-0898 |
| NPI Number | 1972218477 |
|---|---|
| Provider Enumeration Date | 01/18/2023 |
| Last Update Date | 04/01/2024 |
| Certification Date | 04/01/2024 |
| Medicare PECOS PAC ID | 1254864713 |
|---|---|
| Medicare Enrollment ID | O20241023001842 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972218477 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Gabrielle Waters |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1073047742 PECOS PAC ID: 8820431729 Enrollment ID: I20240207003712 |
| Provider Name | Benjamin Gatliff |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1316276645 PECOS PAC ID: 3779924071 Enrollment ID: I20240517001730 |
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