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General NPI Number Information
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NPI Number | 1215514476
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Entity Type | Organization
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Legal Business Name | LIBERATING COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 03/25/2021
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Last Update Date | 04/15/2021
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Provider Practice Location Address
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Address Line | 265 W PIKE ST STE 4
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4896
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Country | US
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Telephone | 770-284-0906
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Fax | 678-407-4444
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Provider Business Mailing Address
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Address Line | 265 W PIKE ST STE 4
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4896
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Country | US
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Telephone | 770-284-0906
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Fax | 678-407-4444
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Authorized Official
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Title or Position | OWNER/CLINICAL DIRECTOR
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Name | DR. ASHLENN A. VON WIEGAND
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Credential | PH.D
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Telephone | 470-236-9864
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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