Provider Demographics
NPI:1174071666
Name:TOTAL CONTROL BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:TOTAL CONTROL BEHAVIORAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMFT
Authorized Official - Phone:678-760-5365
Mailing Address - Street 1:748 HIGHWAY 36 E
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-3248
Mailing Address - Country:US
Mailing Address - Phone:678-760-5365
Mailing Address - Fax:866-217-7073
Practice Address - Street 1:210 S 13TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-2704
Practice Address - Country:US
Practice Address - Phone:678-760-5365
Practice Address - Fax:866-217-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 101YP2500X
GALPC000524302F00000X
GAMFT000232302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA889079225BMedicaid
GA889079225AMedicaid
GA003190902AMedicaid