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General NPI Number Information
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NPI Number | 1568959591
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Entity Type | Organization
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Legal Business Name | ACTIVATING WELLNESS WITHIN, LLC
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Dates
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Enumeration Date | 04/16/2018
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Last Update Date | 04/16/2018
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Provider Practice Location Address
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Address Line | 4153 FLAT SHOALS PKWY STE 324-A
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City | DECATUR
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State | GA
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Zip | 30034-4106
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Country | US
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Telephone | 404-645-9292
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Fax |
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Provider Business Mailing Address
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Address Line | 4153 FLAT SHOALS PKWY STE 324-A
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City | DECATUR
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State | GA
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Zip | 30034-4106
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Country | US
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Telephone | 404-645-9292
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENIKA HOLLOWAY
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Credential |
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Telephone | 404-645-9292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 006307
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License Number State | GA
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