Healthcare Provider Details

I. General information

NPI: 1407673148
Provider Name (Legal Business Name): ACTIVE RESILIENCE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 AUBURN AVE NE APT 228
ATLANTA GA
30312-1980
US

IV. Provider business mailing address

659 AUBURN AVE NE APT 228
ATLANTA GA
30312-1980
US

V. Phone/Fax

Practice location:
  • Phone: 678-658-3699
  • Fax:
Mailing address:
  • Phone: 678-658-3699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: JUNIA BAKER
Title or Position: CLINICAL DIRECTOR
Credential: LPC CPCS
Phone: 678-658-3699