Healthcare Provider Details

I. General information

NPI: 1699372094
Provider Name (Legal Business Name): 5678DANCENOW.INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 JONESBORO RD
FOREST PARK GA
30297-1089
US

IV. Provider business mailing address

4645 JACKYBELL TRL
DECATUR GA
30034-6350
US

V. Phone/Fax

Practice location:
  • Phone: 770-369-6999
  • Fax:
Mailing address:
  • Phone: 770-369-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AYESHA TREACHEA WATSON
Title or Position: CEO
Credential: MS
Phone: 770-369-6999