MEDICARE: COUNSELING, HYPNOTHERAPY, AND LIFE COACHING SERVICES OF HIRAM

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	004731	GA
2	261QM0850X	Adult Mental Health Clinic/Center	004731	GA

General Provider Information

NPI Number	:	1952640302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING, HYPNOTHERAPY, AND LIFE COACHING SERVICES OF HIRAM

Provider Business Mailing Address
First Line	:	44 DARBY'S CROSSING DRIVE
Second Line	:	SUITE 206H
City	:	HIRAM
State	:	GA
Zip	:	30141-6029
Country	:	US
Telephone Number	:	678-978-0464
Fax Number	:	678-715-8796

Provider Business Practice Location Address
First Line	:	44 DARBY'S CROSSING DRIVE
Second Line	:	SUITE 206H
City	:	HIRAM
State	:	GA
Zip	:	30141-6029
Country	:	US
Telephone Number	:	678-978-0464
Fax Number	:	678-715-8796

Authorized Official
Title or Position	:	OWNER/LIC. PROF. COUNSELOR
Name	:	MS. CHRISTINE JANE MEZZA
Credential	:	LPC
Telephone Number	:	678-978-0464

Provider Enumeration Date	:	02/05/2013
Last Update Date	:	02/05/2013

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