MEDICARE: EXODUS CONSULTING, TRAINING & WELLNESS SERVICES, 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1184266850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXODUS CONSULTING, TRAINING & WELLNESS SERVICES, LLC

Provider Business Mailing Address
First Line	:	105 COLLEGE CT
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-4402
Country	:	US
Telephone Number	:	478-293-8503
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 COLLEGE CT
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-4402
Country	:	US
Telephone Number	:	478-293-8503
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. TALISHA GAYE CARTER-MOODY
Credential	:	LPC
Telephone Number	:	478-293-8503

Provider Enumeration Date	:	10/14/2019
Last Update Date	:	10/14/2019

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