Healthcare Provider Details

I. General information

NPI: 1891278321
Provider Name (Legal Business Name): EVERLASTING PEACE COUNSELING AND SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 WYNNTON RD STE 206
COLUMBUS GA
31906-5820
US

IV. Provider business mailing address

PO BOX 12225
COLUMBUS GA
31917-2225
US

V. Phone/Fax

Practice location:
  • Phone: 706-464-4597
  • Fax:
Mailing address:
  • Phone: 706-464-8539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD DUBOSE
Title or Position: OWNER /PRESIDENT
Credential: LPC
Phone: 706-464-8539