Organization
DEVEREUX FOUNDATION
Active
Other names
Devereux Georgia Treatment Network
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARIO BOLIVAR JR. (EXECUTIVE DIRECTOR)
(687) 303-2669
Entity
Organization
Contact information
Practice address
1291 STANLEY RD NW, KENNESAW, GA 30152-4359
(770) 427-0147
Mailing address
1283 KENNESTONE CIR, SUITE 100, MARIETTA, GA 30066-6029
(770) 427-0147
(770) 423-1502
Taxonomy
Speciality
Code
Description
License number
State
323P00000X
Psychiatric Residential Treatment Facility
Primary
5910
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0002464004
—
WV
05
—
087592297A
—
GA
05
—
3404521
—
NC
05
—
700401000
—
MD
Enumeration date
11/07/2006
Last updated
01/16/2009
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