=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104665074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADULT AND CHILD COUNSELING OF ATHENS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2024
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 598 S MILLEDGE AVE STE D
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30605-1262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-919-9392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 598 S MILLEDGE AVE STE D
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30605-1262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-919-9392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SHANNON MILLAN
-----------------------------------------------------
Credential | LPC, NCC
-----------------------------------------------------
Telephone | 706-919-9392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------