Healthcare Provider Details

I. General information

NPI: 1184384372
Provider Name (Legal Business Name): HER WELLNESS CIRCLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 SANDY PLAINS RD STE 493
MARIETTA GA
30066-3068
US

IV. Provider business mailing address

3605 SANDY PLAINS RD STE 493
MARIETTA GA
30066-3068
US

V. Phone/Fax

Practice location:
  • Phone: 678-538-9614
  • Fax: 678-538-9613
Mailing address:
  • Phone: 678-538-9614
  • Fax: 678-538-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. EBONY PETERSON
Title or Position: OWNER
Credential: LCSW
Phone: 678-538-9614