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General NPI Number Information
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NPI Number | 1053958611
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Entity Type | Organization
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Legal Business Name | MBR COUNSELING SERVICES
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Dates
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Enumeration Date | 12/03/2019
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | 2900 CHAMBLEE TUCKER RD BLDG 5
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City | ATLANTA
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State | GA
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Zip | 30341-4100
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Country | US
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Telephone | 404-468-4558
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 473
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City | CLARKSTON
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State | GA
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Zip | 30021-0473
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TIESHEKIA FOWLKS
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Credential | LLPC
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Telephone | 404-468-4558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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