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General NPI Number Information
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NPI Number | 1669898987
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Entity Type | Organization
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Legal Business Name | ELISE PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 03/11/2014
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Last Update Date | 03/11/2014
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Provider Practice Location Address
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Address Line | 4222 CHESTNUT LAKE AVE
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City | LITHONIA
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State | GA
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Zip | 30038-4568
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Country | US
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Telephone | 770-434-4448
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Fax | 770-434-4449
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Provider Business Mailing Address
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Address Line | 1330 CONCORD RD SE SUITE
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City | SMYRNA
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State | GA
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Zip | 30080-4373
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Country | US
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Telephone | 770-434-4448
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Fax | 770-434-4449
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Authorized Official
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Title or Position | OWNER
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Name | DR. REGINA WARD
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Credential | EDD
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Telephone | 770-434-4448
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC009380
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License Number State | GA
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