Healthcare Provider Details

I. General information

NPI: 1396034427
Provider Name (Legal Business Name): KISHA LOVE LPC, CPCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 KENTUCKY ST
SCOTTDALE GA
30079-1124
US

IV. Provider business mailing address

PO BOX 1761
KENNESAW GA
30156-8761
US

V. Phone/Fax

Practice location:
  • Phone: 678-274-2823
  • Fax: 678-398-7760
Mailing address:
  • Phone: 404-543-4687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007310
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007310
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: