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Behavioral Health Resource and Provider Submission Form

This form is for behavioral health providers, facilities and programs to submit their new and/or updated information to Willowbrooke at Tanner. We look forward to learning more about the resources you have to offer.  For more information or if you have questions, please call 770.812.3970.

Submitter Name:  *
Date Submitted  *
Department Name: 
Type of Change:  *
Type of Program/Provider:  *
Phone:  *
Fax:  *
Contact E-mail Address:  *
Provider or Program Name:  *
License No. of Facility or Licensing Body: 
NPI Number: 
Who Regulates/Audits Facility: 
Date of Last Audit (agency only): 
License No. of Provider or Licensee: 
NPI Number: 
Provider or Program Address: 
Provider/Program Phone: 
Web Site: 
Counties served (please list): 
Ages Served: 
Insurance Accepted (list): 
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