MEDICARE: SOS COUNSELING AND CONSULTATION GROUP, 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	251S00000X	Community/Behavioral Health Agency
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	CSW005953	GA
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1538646401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOS COUNSELING AND CONSULTATION GROUP, LLC

Provider Business Mailing Address
First Line	:	2336 WISTERIA DR STE 440
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-6160
Country	:	US
Telephone Number	:	770-733-1469
Fax Number	:

Provider Business Practice Location Address
First Line	:	2336 WISTERIA DR STE 440
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-6160
Country	:	US
Telephone Number	:	770-733-1469
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KABIAN BROWN
Credential	:	LCSW
Telephone Number	:	210-560-0959

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	01/09/2020

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