Healthcare Provider Details

I. General information

NPI: 1952640302
Provider Name (Legal Business Name): COUNSELING, HYPNOTHERAPY, AND LIFE COACHING SERVICES OF HIRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 DARBY'S CROSSING DRIVE SUITE 206H
HIRAM GA
30141-6029
US

IV. Provider business mailing address

44 DARBY'S CROSSING DRIVE SUITE 206H
HIRAM GA
30141-6029
US

V. Phone/Fax

Practice location:
  • Phone: 678-978-0464
  • Fax: 678-715-8796
Mailing address:
  • Phone: 678-978-0464
  • Fax: 678-715-8796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number004731
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number004731
License Number StateGA

VIII. Authorized Official

Name: MS. CHRISTINE JANE MEZZA
Title or Position: OWNER/LIC. PROF. COUNSELOR
Credential: LPC
Phone: 678-978-0464