Healthcare Provider Details

I. General information

NPI: 1700550621
Provider Name (Legal Business Name): IMPACT COACHING CONSULTING AND COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 BEAVER RD
HIGHLAND SPRINGS VA
23075-2404
US

IV. Provider business mailing address

1248 CARMIA WAY # 1053
NORTH CHESTERFIELD VA
23235-4750
US

V. Phone/Fax

Practice location:
  • Phone: 804-243-4939
  • Fax:
Mailing address:
  • Phone: 804-243-4939
  • 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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIATHE GARNES
Title or Position: OWNER
Credential: MS, QMHP-A,C
Phone: 804-243-4939