Healthcare Provider Details

I. General information

NPI: 1689328866
Provider Name (Legal Business Name): FRESH START COUNSELING AND CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 CORPORATE CENTER DR STE C
STOCKBRIDGE GA
30281-7376
US

IV. Provider business mailing address

225 EXPEDITION DR
ELLENWOOD GA
30294-2276
US

V. Phone/Fax

Practice location:
  • Phone: 470-844-6908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JACLYN HALLUMS
Title or Position: OWNER
Credential:
Phone: 470-844-6908