Healthcare Provider Details

I. General information

NPI: 1154625424
Provider Name (Legal Business Name): FLYING CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4680 POLO LN SE
ATLANTA GA
30339-5346
US

IV. Provider business mailing address

4680 POLO LN SE
ATLANTA GA
30339-5346
US

V. Phone/Fax

Practice location:
  • Phone: 404-512-0834
  • Fax: 770-832-3969
Mailing address:
  • Phone: 404-512-0834
  • Fax: 770-832-3969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LISSA B CORCORAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 404-512-0834