Healthcare Provider Details

I. General information

NPI: 1760004758
Provider Name (Legal Business Name): CIRCLE OF THERAPEUTIC ALLIANCE AND CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 BURKE ST STE 250
STOCKBRIDGE GA
30281-3430
US

IV. Provider business mailing address

159 BURKE ST STE 205
STOCKBRIDGE GA
30281-3428
US

V. Phone/Fax

Practice location:
  • Phone: 470-206-1260
  • Fax: 678-550-4207
Mailing address:
  • Phone: 470-206-1262
  • Fax: 404-738-2932

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 Number
License Number State

VIII. Authorized Official

Name: DR. NAOMI BLACK
Title or Position: CEO/MANAGING DIRECTOR
Credential: DEL
Phone: 470-206-1260