Healthcare Provider Details

I. General information

NPI: 1831698869
Provider Name (Legal Business Name): IN CONTROL COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3895 MOUNTAIN VIEW RD NW
KENNESAW GA
30152-2388
US

IV. Provider business mailing address

3895 MOUNTAIN VIEW RD NW
KENNESAW GA
30152-2388
US

V. Phone/Fax

Practice location:
  • Phone: 678-783-4075
  • Fax: 404-795-2055
Mailing address:
  • Phone: 470-632-0762
  • Fax: 404-795-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC009735
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009735
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC009735
License Number StateGA

VIII. Authorized Official

Name: DAMETRIA CARSON
Title or Position: THERAPIST/OWNER
Credential: LPC
Phone: 470-632-0762