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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.
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Submitter Name:
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Date Submitted:
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Department Name:
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Type of Change:
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Type of Program/Provider:
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Phone:
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Fax:
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Contact E-mail Addres:
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Provider or Program Name:
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License No. of Facility or Licensing

Body:
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NPI Number:
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Who Regulates/Audits Facility:
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Date of Last Audit (agency only):
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License No. of Provider or Licensee:
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Provider or Program Address:
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Provider/Program Phone:
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Web Site:
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Counties Served (please list):
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Specialties:
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Ages Served:
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Insurance Accepted (list):
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SUBMIT

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