Healthcare Provider Details

I. General information

NPI: 1588253280
Provider Name (Legal Business Name): BOUNDLESS LOVE PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2021
Last Update Date: 12/25/2024
Certification Date: 12/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 STEEPLE CHASE TRL
DALLAS GA
30132-8305
US

IV. Provider business mailing address

34 STEEPLE CHASE TRL
DALLAS GA
30132-8305
US

V. Phone/Fax

Practice location:
  • Phone: 470-985-6858
  • Fax: 678-669-1898
Mailing address:
  • Phone: 470-985-6858
  • Fax: 678-669-1898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SUZETTE DELICIA WILLIAMS
Title or Position: PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 678-250-6026