11D2161626 CLIA NUMBER - GEORGIA BEHAVIORAL HEALTH PRACTITIONER CLINIC

Laboratory Demographics

  • CLIA Code: 11D2161626
  • Facility Name: GEORGIA BEHAVIORAL HEALTH PRACTITIONER CLINIC
  • Facility Address: 2206 HANFRED LANE, SUITE 103
    TUCKER, GA
    ZIP 30084
  • Facility Phone: 678 831-6429
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: LOUISE WISE
  • NPI Number: 1699239475
  • Taxonomy: 261QM0801X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 11D2161626
LAB Type Practitioner Other
Facility Name GEORGIA BEHAVIORAL HEALTH PRACTITIONER CLINIC
Street 2206 HANFRED LANE, SUITE 103
City TUCKER
State GA
ZIP 30084
Phone 678 831-6429
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/7/2025
Certificate Expiration Date 2/6/2027
Facility Type Practitioner Other
Lab Director LOUISE WISE

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This page was last updated on: 6/4/2025