Healthcare Provider Details

I. General information

NPI: 1699188367
Provider Name (Legal Business Name): HEALING OUR VILLAGE OF MARYLAND, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 N MAIN ST
JONESBORO GA
30236-3567
US

IV. Provider business mailing address

405 BENJAMIN CIR
FAYETTEVILLE GA
30214-3346
US

V. Phone/Fax

Practice location:
  • Phone: 800-788-0941
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LENORE COLEMAN
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 703-795-1983