=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043051501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING SPACE OF ATHENS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2024
-----------------------------------------------------
Last Update Date | 10/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HUNTINGTON RD STE 703
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-7214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-425-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 HUNTINGTON RD STE 703
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-7214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-425-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | ALINE ROBOLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-425-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------