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: ---Select One-- Add Delete Edit * Type of Program/Provider: ---Select One-- Other Group home Private provider Shelter Social service agency * Phone: * Fax: * Contact E-mail Addres: * 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: * Provider or Program Address: * Provider/Program Phone: * Web Site: * Counties Served (please list): * Specialties: * Ages Served: * Insurance Accepted (list): * Ae you interested in touring Willowbrooke at Tanner? ---Select One-- Yes No SUBMIT SUBMIT