=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114423829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIVOT POINT COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2018
-----------------------------------------------------
Last Update Date | 04/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3225 SHALLOWFORD RD STE 710
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-7026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-948-6003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3225 SHALLOWFORD RD STE 710
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-7026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER HOLLINGSWORTH
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 678-948-6003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | LPC006594
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------