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Organization
BLACK SHEEP TRAUMA AND RECOVERY LLC
Active
Organization
BLACK SHEEP TRAUMA AND RECOVERY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN WIDENER LPC, LMFT (OWNER)
(678) 577-8795
Entity
Organization
Contact information
Practice address
125 E MONROE ST, THOMASVILLE, GA 31792-5142
(404) 860-2111
Mailing address
125 E MONROE ST, THOMASVILLE, GA 31792-5142
(678) 577-8795
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
106H00000X
Marriage & Family Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003226805A
—
GA
Enumeration date
01/20/2022
Last updated
01/25/2022
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