=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053248211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIDA COUNSELING AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2026
-----------------------------------------------------
Last Update Date | 05/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 N SELVIDGE ST STE 302
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-280-3214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 CHATTANOOGA AVE APT A300
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-8887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-280-3214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERPAIST
-----------------------------------------------------
Name | KEISHA MARIE HERNANDEZ
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 706-280-3214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------