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General NPI Number Information
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NPI Number | 1659087351
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Entity Type | Organization
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Legal Business Name | BLACK BUTTERFLY QUEENS LIFE COACHING LLC
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Dates
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Enumeration Date | 01/25/2023
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Last Update Date | 01/27/2023
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Provider Practice Location Address
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Address Line | 320 LANIER AVE W STE 240
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-7547
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Country | US
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Telephone | 770-282-9323
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Fax |
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Provider Business Mailing Address
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Address Line | 1244 HIGHWAY 138 SW # 1066
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City | RIVERDALE
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State | GA
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Zip | 30296-1402
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Country | US
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Telephone | 770-282-9323
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEMETRIA YVETTE WINTERS
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Credential | RN
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Telephone | 770-282-9323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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