Healthcare Provider Details

I. General information

NPI: 1366730079
Provider Name (Legal Business Name): MY EPIPHANY COUNSELING AND CONSULTATION SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MILLBROOK VILLAGE DR
TYRONE GA
30290-3605
US

IV. Provider business mailing address

809 KOHL DR
MCDONOUGH GA
30253-7489
US

V. Phone/Fax

Practice location:
  • Phone: 678-263-8830
  • Fax: 678-782-5491
Mailing address:
  • Phone: 678-263-8830
  • Fax: 678-782-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number005233
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. JEMEKA LASHAY STALLWORTH
Title or Position: CLINICAL DIRECTOR/CO-OWNER
Credential: LPC
Phone: 205-919-6327