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General NPI Number Information
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NPI Number | 1124844600
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Entity Type | Organization
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Legal Business Name | CONSCIOUS RENEWING THERAPY
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Dates
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Enumeration Date | 11/29/2024
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Last Update Date | 11/29/2024
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Provider Practice Location Address
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Address Line | 3100 STONE BRIDGE TRL SW
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City | CONYERS
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State | GA
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Zip | 30094-6713
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Country | US
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Telephone | 470-263-6320
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Fax |
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Provider Business Mailing Address
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Address Line | 3863 HIGHWAY 138 SE # 1379
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-4143
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Country | US
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Telephone | 470-263-7264
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MEKEYA BLAKE
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Credential | DSW, LCSW
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Telephone | 470-263-6320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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