=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336591775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY SECRET GARDEN COUNSELING SERVICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2016
-----------------------------------------------------
Last Update Date | 07/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2985 CHEROKEE ST NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30144-2863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-218-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2985 CHEROKEE ST NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30144-2863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-218-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MRS. MARGARET B AST
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 770-218-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC007952
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------