Healthcare Provider Details

I. General information

NPI: 1750206652
Provider Name (Legal Business Name): OUR HEALING SPACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 TWIN HILL RD
AUSTELL GA
30168-7724
US

IV. Provider business mailing address

1445 WOODMONT LN NW # 1576
ATLANTA GA
30318-2866
US

V. Phone/Fax

Practice location:
  • Phone: 678-399-2070
  • Fax: 404-537-6836
Mailing address:
  • Phone: 678-399-2070
  • Fax: 404-537-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARIUS HAYNES
Title or Position: ADMINISTRATOR
Credential: LPC
Phone: 678-439-9804