Healthcare Provider Details

I. General information

NPI: 1023951597
Provider Name (Legal Business Name): WIWAC CONSULTING FIRM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PERRY ST STE 204
NEWNAN GA
30263-1918
US

IV. Provider business mailing address

388 BULLSBORO DR STE 174
NEWNAN GA
30263-1069
US

V. Phone/Fax

Practice location:
  • Phone: 678-633-5104
  • Fax: 678-214-2380
Mailing address:
  • Phone: 678-633-5104
  • Fax: 678-214-2380

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 Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA EZZARD
Title or Position: DIRECTOR
Credential:
Phone: 678-633-5104