Healthcare Provider Details

I. General information

NPI: 1144057357
Provider Name (Legal Business Name): ETHENIA ALICEE SCOTT C-EM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 PEACHTREE ST NW
ATLANTA GA
30303-1202
US

IV. Provider business mailing address

1328 PEACHTREE ST NE
ATLANTA GA
30309-3209
US

V. Phone/Fax

Practice location:
  • Phone: 838-333-3989
  • Fax:
Mailing address:
  • Phone: 838-333-3989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: