MEDICARE: MAUVESCAPE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY003998	GA

General Provider Information

NPI Number	:	1033518048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAUVESCAPE LLC

Provider Business Mailing Address
First Line	:	675 SEMINOLE AVE NE STE 307
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30307-3416
Country	:	US
Telephone Number	:	678-701-9559
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 SEMINOLE AVE NE STE 307
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30307-3416
Country	:	US
Telephone Number	:	678-701-9559
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHANTEA D WILLIAMS
Credential	:	PH.D.
Telephone Number	:	678-701-9559

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	03/31/2016

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Directions to “MAUVESCAPE LLC ” Practice Location

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