Healthcare Provider Details

I. General information

NPI: 1205694544
Provider Name (Legal Business Name): EMBODIED THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 PAVILION CT
MCDONOUGH GA
30253-6666
US

IV. Provider business mailing address

806 PAVILION CT
MCDONOUGH GA
30253-6666
US

V. Phone/Fax

Practice location:
  • Phone: 404-805-1828
  • Fax: 678-466-7561
Mailing address:
  • Phone: 404-805-1828
  • Fax: 678-466-7561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAQUITA SHORTS
Title or Position: OWNER
Credential:
Phone: 404-805-1828