=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164839304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVE BALANCED COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2014
-----------------------------------------------------
Last Update Date | 01/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2140 MCGEE RD STE C700
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078-7018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-547-1960
-----------------------------------------------------
Fax | 770-680-5715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6194 WATERTON WAY
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-547-1960
-----------------------------------------------------
Fax | 770-680-5715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LORNA BEVERLY BOWEN
-----------------------------------------------------
Credential | LPC, LMFT
-----------------------------------------------------
Telephone | 404-547-1960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | APC003243
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT0011342
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------