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General NPI Number Information
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NPI Number | 1750805875
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Entity Type | Organization
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Legal Business Name | SANKOFA WELLNESS GROUP
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Dates
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Enumeration Date | 07/31/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2001 MARTIN LUTHER KING JR DR SW STE 201
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City | ATLANTA
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State | GA
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Zip | 30310-1101
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Country | US
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Telephone | 404-476-5498
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Fax |
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Provider Business Mailing Address
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Address Line | 2290 LAKE ROYALE DR
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City | RIVERDALE
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State | GA
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Zip | 30296-1896
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Country | US
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Telephone | 678-709-8002
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DESIREA RUSSELL
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Credential | MS, LPC
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Telephone | 678-709-8002
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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 |
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License Number State |
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