Healthcare Provider Details

I. General information

NPI: 1033556659
Provider Name (Legal Business Name): BLACK SWAN ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BUFORD HWY NE STE 501
ATLANTA GA
30329-2149
US

IV. Provider business mailing address

1313 OAK ST SW
ATLANTA GA
30310-1653
US

V. Phone/Fax

Practice location:
  • Phone: 404-832-0604
  • Fax:
Mailing address:
  • Phone: 678-748-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007304
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC007304
License Number StateGA

VIII. Authorized Official

Name: MS. MIKAELA NICOLE HEARD
Title or Position: OWNER, LEAD THERAPIST
Credential: M.ED, LPC
Phone: 404-832-0604