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General NPI Number Information
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NPI Number | 1710423660
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Entity Type | Organization
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Legal Business Name | HEALING SPACE, LLC
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 01/17/2017
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Provider Practice Location Address
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Address Line | 3883 ROGERS BRIDGE RD STE. 203A
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City | DULUTH
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State | GA
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Zip | 30097-2802
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Country | US
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Telephone | 404-538-3387
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Fax |
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Provider Business Mailing Address
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Address Line | 1938 JOHNSON FERRY RD NE UNIT G
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City | BROOKHAVEN
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State | GA
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Zip | 30319-5011
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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/PRINCIPAL
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Name | LYDIA JOHNSON
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Credential |
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Telephone | 404-538-3387
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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 | LPC007987
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License Number State | GA
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