Healthcare Provider Details

I. General information

NPI: 1104798438
Provider Name (Legal Business Name): AMBITIOUS COMPASSION WELLNESS COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MARTIN LUTHER KING JR DR SW STE 210
ATLANTA GA
30310-5800
US

IV. Provider business mailing address

2290 LAKE ROYALE DR
RIVERDALE GA
30296-1896
US

V. Phone/Fax

Practice location:
  • Phone: 404-839-0218
  • Fax: 470-878-3156
Mailing address:
  • Phone: 404-839-0218
  • Fax: 470-878-3156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DESIREA R RUSSELL
Title or Position: CEO
Credential: MS, CRC, LPC
Phone: 678-709-8002