| Changing Phases Behavioral Support, Inc | |
|
3655 Canton Rd Ste 201 Marietta GA 30066 | |
| (707) 261-1627 | |
| (707) 702-5966 |
| Full Name | Changing Phases Behavioral Support, Inc |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 3655 Canton Rd Ste 201, Marietta, Georgia |
| Authorized Official Name and Position | Mya S Cullins (VICE PRESIDENT) |
| Authorized Official Contact | 3362686469 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Changing Phases Behavioral Support, Inc 3655 Canton Rd Marietta GA 30066-2690 Ph: (770) 726-1162 | Changing Phases Behavioral Support, Inc 3655 Canton Rd Ste 201 Marietta GA 30066 Ph: (707) 261-1627 |
| NPI Number | 1497094205 |
|---|---|
| Provider Enumeration Date | 02/14/2013 |
| Last Update Date | 08/17/2018 |
| Medicare PECOS PAC ID | 4183978729 |
|---|---|
| Medicare Enrollment ID | O20181116001202 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1497094205 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 25937 (Georgia) | Secondary |
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Miles D Johnson |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1568419844 PECOS PAC ID: 2466437157 Enrollment ID: I20040618000358 |
| Provider Name | Michael Austin |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1134155153 PECOS PAC ID: 3870543861 Enrollment ID: I20050127000429 |
| Provider Name | Turquoise Allen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013458918 PECOS PAC ID: 3476891359 Enrollment ID: I20190610003085 |
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