=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659804300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTIC LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2017
-----------------------------------------------------
Last Update Date | 04/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 W PONCE DE LEON AVE SUITE 835
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-295-1359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 W PONCE DE LEON AVE SUITE 835
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-295-1359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. REBECCA CLEGG
-----------------------------------------------------
Credential | MS, LPC, CEDS
-----------------------------------------------------
Telephone | 404-295-1359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC004898
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------