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General NPI Number Information
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NPI Number | 1588295323
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Entity Type | Organization
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Legal Business Name | STREAMS OF LIFE COUNSELING AND EDUCATIONAL SERVICES, LLC
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Dates
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Enumeration Date | 01/30/2020
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Last Update Date | 01/30/2020
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Provider Practice Location Address
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Address Line | 990 IRIS DR SW STE 103
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City | CONYERS
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State | GA
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Zip | 30094-6602
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Country | US
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Telephone | 770-369-9984
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 82653
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City | CONYERS
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State | GA
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Zip | 30013-9439
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Country | US
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Telephone | 404-388-7981
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Fax |
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Authorized Official
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Title or Position | CLINICIAN/THERAPIST - MANAGER
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Name | DR. RENA GLASS-DIXON
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Credential | PHD, LCSW
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Telephone | 404-388-7981
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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