=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295398345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETTERSELF COMMUNITY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2019
-----------------------------------------------------
Last Update Date | 04/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6268 OAKDALE RD SE
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-263-6467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1812 EVADALE CT
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-5741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-263-6467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NGONEH BULLARD
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 401-263-6467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------