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General NPI Number Information
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NPI Number | 1124353339
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Entity Type | Organization
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Legal Business Name | PRO- HOLISM PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 10/06/2009
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Last Update Date | 07/16/2020
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Provider Practice Location Address
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Address Line | 2480 WINDY HILL RD SE SUITE 206
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City | MARIETTA
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State | GA
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Zip | 30067-8644
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Country | US
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Telephone | 770-953-0074
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Fax |
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Provider Business Mailing Address
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Address Line | 2480 WINDY HILL RD SE STE 206
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City | MARIETTA
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State | GA
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Zip | 30067-8656
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Country | US
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Telephone | 404-800-5550
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Fax |
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Authorized Official
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Title or Position | HEALTHCARE ADMINISTRATION EXECUTIVE
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Name | DR. REDA COSTON
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Credential | LMP, D.SC., PSYD/PHD
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Telephone | 404-800-5550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | GA
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Taxonomy #6
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State | GA
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Taxonomy #8
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | GA
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