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General NPI Number Information
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NPI Number | 1285287086
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Entity Type | Organization
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Legal Business Name | HER VILLAGE FOUNADATION LLC
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Dates
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Enumeration Date | 07/20/2019
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Last Update Date | 07/20/2019
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Provider Practice Location Address
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Address Line | 8341 GRADY ST
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-6910
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Country | US
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Telephone | 718-570-3446
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Fax |
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Provider Business Mailing Address
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Address Line | 8341 GRADY ST
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-6910
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHANE JANELLE GILL
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Credential | BA, MA
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Telephone | 718-570-3446
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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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