=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497223143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOT BY BREAD ALONE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2018
-----------------------------------------------------
Last Update Date | 11/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2727 BOULDERCREST RD SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30316-4811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-842-2435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2143 SABLESHIRE WAY SE
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-6476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-842-2435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. LANDON B. LEE
-----------------------------------------------------
Credential | EDD
-----------------------------------------------------
Telephone | 770-842-2435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------