Healthcare Provider Details

I. General information

NPI: 1891141248
Provider Name (Legal Business Name): LEONORA CAMILLE AUSTIN DCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 EZRA CHURCH DR NW
ATLANTA GA
30314-1807
US

IV. Provider business mailing address

1690 EZRA CHURCH DR NW
ATLANTA GA
30314-1807
US

V. Phone/Fax

Practice location:
  • Phone: 404-545-1190
  • Fax:
Mailing address:
  • Phone: 404-545-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number10654
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10654
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10654
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: