Healthcare Provider Details

I. General information

NPI: 1568289502
Provider Name (Legal Business Name): RADIANT DISCOVERY GLOBAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 COUNTRY CLUB DR STE C
STOCKBRIDGE GA
30281-7434
US

IV. Provider business mailing address

2388 FOREST DR
JONESBORO GA
30236-4074
US

V. Phone/Fax

Practice location:
  • Phone: 404-754-4557
  • Fax:
Mailing address:
  • Phone: 404-754-4557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEIDRE J WILLIAMS
Title or Position: BUSINESS OWNER
Credential:
Phone: 404-754-4557