Basic Information
| Provider Information | |||||||||
| NPI: | 1871998229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNISON BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 MARY ST | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124497100 | ||||||||
| FaxNumber: | 9124497056 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 MARY ST | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124497100 | ||||||||
| FaxNumber: | 9124497056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2014 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | SIMPSON | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9124497109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 000768963AM | 05 | GA | MEDICAID |