MEDICARE: MS. IMANI SADE HINES LPC

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	101YM0800X	Mental Health Counselor	LPC0114779	GA

General Provider Information

NPI Number	:	1255960662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IMANI SADE HINES LPC

Provider Business Mailing Address
First Line	:	5204 WESTCHESTER LN NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-2549
Country	:	US
Telephone Number	:	757-713-2480
Fax Number	:

Provider Business Practice Location Address
First Line	:	5204 WESTCHESTER LN NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-2549
Country	:	US
Telephone Number	:	757-713-2480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	02/12/2024

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