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General NPI Number Information
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NPI Number | 1114425204
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Entity Type | Organization
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Legal Business Name | AGAPE TRANSFORMATION PRACTICE
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Dates
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Enumeration Date | 01/24/2018
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Last Update Date | 01/24/2018
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Provider Practice Location Address
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Address Line | 235 E PONCE DE LEON AVE STE 103
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City | DECATUR
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State | GA
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Zip | 30030-3412
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Country | US
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Telephone | 678-753-5248
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Fax | 404-585-3054
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Provider Business Mailing Address
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Address Line | 4978 RIVER OVERLOOK WAY
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City | LITHONIA
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State | GA
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Zip | 30038-6234
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Country | US
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Telephone | 678-753-5248
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Fax | 404-585-3054
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Authorized Official
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Title or Position | CEO
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Name | KARRION D LALOR
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Credential | LPC
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Telephone | 678-753-5248
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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 | LPC006638
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License Number State | GA
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