Basic Information
| Provider Information | |||||||||
| NPI: | 1720124043 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNISON BEHAVIORAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SATILLA COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 MARY STREET | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124497100 | ||||||||
| FaxNumber: | 9124497056 | ||||||||
| Practice Location | |||||||||
| Address1: | 1835 W 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126325905 | ||||||||
| FaxNumber: | 9124497056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9124497100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 000606295N | 05 | GA | MEDICAID |