Healthcare Provider Details

I. General information

NPI: 1669934030
Provider Name (Legal Business Name): ONE WELLNESS BOUTIQUE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 MONROE DR NE STE A102-450
ATLANTA GA
30308-1793
US

IV. Provider business mailing address

931 MONROE DR NE STE A102-450
ATLANTA GA
30308-1793
US

V. Phone/Fax

Practice location:
  • Phone: 404-789-4079
  • Fax: 877-833-3855
Mailing address:
  • Phone: 404-789-4079
  • Fax: 877-833-3855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. QUE'ANA LACHE MORRIS JACKSON
Title or Position: OWNER
Credential:
Phone: 404-789-4079