Healthcare Provider Details

I. General information

NPI: 1801286968
Provider Name (Legal Business Name): INNOVATIVE COUNSELING SOLUTIONS & PREMARITAL BLISS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 PACES FERRY RD SE
ATLANTA GA
30339-5702
US

IV. Provider business mailing address

2900 PACES FERRY RD SE
ATLANTA GA
30339-5702
US

V. Phone/Fax

Practice location:
  • Phone: 404-829-4121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007299
License Number StateGA

VIII. Authorized Official

Name: MAYI DIXON
Title or Position: OWNER & PSYCHOTHERAPIST
Credential: LPC
Phone: 404-829-4121