Healthcare Provider Details

I. General information

NPI: 1619255338
Provider Name (Legal Business Name): EXTENDED GRACE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 SCENIC HIGHWAY SOUTH SUITE 313
SNELLVILLE GA
30078-3115
US

IV. Provider business mailing address

2330 SCENIC HIGHWAY SOUTH, SUITE 313
SNELLVILLE GA
30078-3115
US

V. Phone/Fax

Practice location:
  • Phone: 678-892-6969
  • Fax: 770-785-7250
Mailing address:
  • Phone: 678-892-6969
  • Fax: 770-785-7250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC004880
License Number StateGA

VIII. Authorized Official

Name: MRS. REBECCA ANN SCOTT
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 404-427-7321