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General NPI Number Information
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NPI Number | 1467990119
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Entity Type | Organization
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Legal Business Name | INTROSPECTION & REFLECTION
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Dates
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Enumeration Date | 02/02/2017
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Last Update Date | 02/02/2017
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Provider Practice Location Address
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Address Line | 184 HAMILTON GROVE DR
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City | POOLER
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State | GA
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Zip | 31322-9644
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Country | US
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Telephone | 912-346-5344
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Fax |
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Provider Business Mailing Address
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Address Line | 184 HAMILTON GROVE DRIVE
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City | POOLER
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State | GA
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Zip | 31322
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Country | US
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Telephone | 912-346-5344
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAYSHA PHIMPHONE
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Credential | LPC
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Telephone | 912-346-5344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health
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License Number | 009203
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License Number State | GA
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