Healthcare Provider Details

I. General information

NPI: 1982061545
Provider Name (Legal Business Name): SWCCOUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 MIMOSA BLVD BLDG C
ROSWELL GA
30075-4410
US

IV. Provider business mailing address

4886 CANDLEWOOD LN
STONE MOUNTAIN GA
30088-1606
US

V. Phone/Fax

Practice location:
  • Phone: 678-680-8731
  • Fax:
Mailing address:
  • Phone: 770-469-0124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License NumberLPC008645
License Number StateGA

VIII. Authorized Official

Name: VERA HOLLOWAY
Title or Position: OWNER
Credential:
Phone: 770-469-0124