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General NPI Number Information
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NPI Number | 1033556659
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Entity Type | Organization
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Legal Business Name | BLACK SWAN ENTERPRISES
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Dates
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Enumeration Date | 05/23/2013
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Last Update Date | 06/12/2014
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Provider Practice Location Address
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Address Line | 2801 BUFORD HWY NE STE 501
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City | ATLANTA
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State | GA
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Zip | 30329-2149
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Country | US
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Telephone | 404-832-0604
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Fax |
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Provider Business Mailing Address
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Address Line | 1313 OAK ST SW
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City | ATLANTA
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State | GA
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Zip | 30310-1653
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Country | US
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Telephone | 678-748-0128
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Fax |
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Authorized Official
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Title or Position | OWNER, LEAD THERAPIST
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Name | MS. MIKAELA NICOLE HEARD
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Credential | M.ED, LPC
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Telephone | 404-832-0604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LPC007304
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC007304
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License Number State | GA
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