Healthcare Provider Details

I. General information

NPI: 1215782362
Provider Name (Legal Business Name): BEACON WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 GREENVILLE ST
LAGRANGE GA
30241-3232
US

IV. Provider business mailing address

205 N LEWIS ST STE A
LAGRANGE GA
30240-2752
US

V. Phone/Fax

Practice location:
  • Phone: 706-881-3441
  • Fax:
Mailing address:
  • Phone: 706-881-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SUJONG CHANG
Title or Position: OWNER/LPC
Credential: LPC
Phone: 706-881-3441