Healthcare Provider Details

I. General information

NPI: 1689041428
Provider Name (Legal Business Name): REACHING ABOVE POVERTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 MEGAN RD
STONE MOUNTAIN GA
30088
US

IV. Provider business mailing address

5401 MEGAN RD
STONE MOUNTAIN GA
30088
US

V. Phone/Fax

Practice location:
  • Phone: 678-651-0097
  • Fax:
Mailing address:
  • Phone: 678-651-0097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELE DRAPER WATSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 678-651-0097