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General NPI Number Information
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NPI Number | 1689072068
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Entity Type | Organization
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Legal Business Name | PLAY WELLNESS LLC
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Dates
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Enumeration Date | 12/16/2014
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Last Update Date | 06/17/2016
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Provider Practice Location Address
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Address Line | 3545 BROAD ST # 80742
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City | ATLANTA
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State | GA
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Zip | 30341-2259
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Country | US
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Telephone | 770-375-8124
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Fax |
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Provider Business Mailing Address
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Address Line | 3545 BROAD ST # 80742
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City | ATLANTA
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State | GA
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Zip | 30341-2259
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. YOLANDA FOUNTAIN
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Credential | PHD, LPC, RPT-S, ACS
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Telephone | 678-871-9355
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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 | LPC006900
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License Number State | GA
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