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General NPI Number Information
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NPI Number | 1609221605
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Entity Type | Organization
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Legal Business Name | THE PEACEFUL PLACE, LLC
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 1799 CLAIRMONT RD
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City | DECATUR
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State | GA
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Zip | 30033-4005
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Country | US
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Telephone | 404-490-0664
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Fax |
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Provider Business Mailing Address
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Address Line | 1799 CLAIRMONT RD
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City | DECATUR
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State | GA
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Zip | 30033-4005
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Country | US
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Telephone | 404-490-0664
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | PATRICK BRYANT
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Credential | LCSW
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Telephone | 404-490-0664
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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 | CSW004964
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License Number State | GA
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