Healthcare Provider Details
I. General information
NPI: 1083142947
Provider Name (Legal Business Name): INTEGRATIVE CAP HEALTH PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 05/23/2017
Last Update Date: 05/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
770 OLD ROSWELL PL STE G400
ROSWELL GA
30076-8635
US
IV. Provider business mailing address
230 CARRIAGE STATION CIR
ROSWELL GA
30075-4655
US
V. Phone/Fax
- Phone: 470-282-1200
- Fax:
- Phone: 404-259-2206
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 171000000X |
| Taxonomy | Military Health Care Provider |
| License Number | 12635154 |
| License Number State | TX |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 174H00000X |
| Taxonomy | Health Educator |
| License Number | 12635154 |
| License Number State | TX |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 175T00000X |
| Taxonomy | Peer Specialist |
| License Number | 12635154 |
| License Number State | TX |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 261QC1500X |
| Taxonomy | Community Health Clinic/Center |
| License Number | 12635154 |
| License Number State | TX |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 405300000X |
| Taxonomy | Prevention Professional |
| License Number | 12635154 |
| License Number State | TX |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 261QC1800X |
| Taxonomy | Corporate Health Clinic/Center |
| License Number | 12635154 |
| License Number State | TX |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 261QH0100X |
| Taxonomy | Health Service Clinic/Center |
| License Number | 12635154 |
| License Number State | TX |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 261QM1100X |
| Taxonomy | Military/U.S. Coast Guard Outpatient Clinic/Center |
| License Number | 12635154 |
| License Number State | TX |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 261QP0905X |
| Taxonomy | State or Local Public Health Clinic/Center |
| License Number | 12635154 |
| License Number State | TX |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 261QP2300X |
| Taxonomy | Primary Care Clinic/Center |
| License Number | 12635154 |
| License Number State | TX |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101YP1600X |
| Taxonomy | Pastoral Counselor |
| License Number | 12635154 |
| License Number State | TX |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 133NN1002X |
| Taxonomy | Nutrition Education Nutritionist |
| License Number | 12635154 |
| License Number State | TX |
| # 13 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 175F00000X |
| Taxonomy | Naturopath |
| License Number | 12635154 |
| License Number State | TX |
VIII. Authorized Official
Name: DR.
LEONIE
V
HARRIS
Title or Position: PROVIDER/ OWNER
Credential: P.H.D
Phone: 404-259-2206
