Provider Demographics
NPI:1487079562
Name:POSITIVE IMPACT RESIDENTIAL SERVICES
Entity type:Organization
Organization Name:POSITIVE IMPACT RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAX
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-730-7604
Mailing Address - Street 1:2189 W PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2334
Mailing Address - Country:US
Mailing Address - Phone:678-887-3263
Mailing Address - Fax:404-687-9871
Practice Address - Street 1:2189 W PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2334
Practice Address - Country:US
Practice Address - Phone:678-887-3263
Practice Address - Fax:404-687-9871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW002378261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)