MEDICARE: HER WELLNESS CIRCLE, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251K00000X	Public Health or Welfare Agency
2	251S00000X	Community/Behavioral Health Agency
3	253Z00000X	In Home Supportive Care Agency
4	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1184384372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HER WELLNESS CIRCLE, LLC

Provider Business Mailing Address
First Line	:	3605 SANDY PLAINS RD STE 493
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-3068
Country	:	US
Telephone Number	:	678-538-9614
Fax Number	:	678-538-9613

Provider Business Practice Location Address
First Line	:	3605 SANDY PLAINS RD STE 493
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-3068
Country	:	US
Telephone Number	:	678-538-9614
Fax Number	:	678-538-9613

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. EBONY PETERSON
Credential	:	LCSW
Telephone Number	:	678-538-9614

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	12/29/2021

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