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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