Healthcare Provider Details

I. General information

NPI: 1104154806
Provider Name (Legal Business Name): THE EMPOWERMENT ACADEMY FOR GIRLS AND WOMEN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7314 WAGON WHEEL CT
JONESBORO GA
30236-2545
US

IV. Provider business mailing address

7314 WAGON WHEEL CT
JONESBORO GA
30236-2545
US

V. Phone/Fax

Practice location:
  • Phone: 404-665-7935
  • Fax:
Mailing address:
  • Phone: 404-665-7935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number000002
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00000001
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number000003
License Number StateGA

VIII. Authorized Official

Name: MS. NIKKI MACHARIA VENISEE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 404-665-7935