Organization
MCINTOSH TRAIL CSB
Active
Other names
Fayette Community Options
Organization subpart
No
Provider details
NPI number
Authorized official
MIKE HUBBARD LCSW (CEO)
(770) 358-8251
Entity
Organization
Contact information
Practice address
160 CARNEGIE PL, FAYETTEVILLE, GA 30214-3905
(770) 461-1351
Mailing address
1435 N EXPRESSWAY, SUITE 301, GRIFFIN, GA 30223-9016
(770) 358-8250
(770) 229-3223
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000603435J
—
GA
05
—
000603435K
—
GA
Enumeration date
02/08/2008
Last updated
12/17/2015
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