Healthcare Provider Details

I. General information

NPI: 1396248860
Provider Name (Legal Business Name): KEY ESSENTIALS COUNSELING AND CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 SILVERGATE LN
MABLETON GA
30126-1273
US

IV. Provider business mailing address

1119 SILVERGATE LN
MABLETON GA
30126-1273
US

V. Phone/Fax

Practice location:
  • Phone: 404-542-8787
  • Fax:
Mailing address:
  • Phone: 404-542-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberCSW003802
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberCSW003802
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberCSW003802
License Number StateGA

VIII. Authorized Official

Name: KEVIN DUANE LARRY
Title or Position: THERAPIST
Credential: LMSW, LCSW
Phone: 404-988-7120